Strategies and Challenges of a Safe Fireplace Program in Rural Kenya: A Qualitative Study.

There is a lack of information on effective burn prevention strategies. The objective of this study was to examine a safe fireplace program, as a method of burn prevention, in a resource-limited setting. We conducted a qualitative, phenomenological study at a community health and development program for a rural population in Kenya. Semi-structured, in-depth interviews were conducted with a purposive sample of community health workers involved with the safe fireplace program. Data were reviewed iteratively and coded independently by two researchers using NVivo 12. The study included five participants. Reflections from participants fell into three main domains: (1) effective methods of education, (2) strategies to incorporate stakeholders, and (3) implementation challenges. The results of this study emphasize the importance of community engagement in implementing a successful burn injury prevention program in a resource-limited setting. The participants involved in this study reported that rather than focusing on resources outside the community, effective methods of education and strategies for incorporating stakeholders depended on involving peers and community leaders. The challenges to the program were similarly specific to community concerns about resources and maintenance. These findings provide information to guide future community health programs in creating successful models for burn prevention strategies in resource-limited areas.

Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa.

BACKGROUND: Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries. METHODS: Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored. RESULTS: One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level. CONCLUSIONS: Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.

Building cardiac surgical programs in lower-middle income countries.

Objectives: Medical care in low-income countries is often limited by inadequate resources, treatment facilities, and the necessary infrastructure for healthcare delivery. We hypothesized that the development of an independently functioning, internationally supported Kenyan cardiac surgical training program could address these issues through targeted investment. Methods: A review was conducted of the programmatic structure and clinical outcomes from January 2008 to October 2021 at Tenwek Hospital, Bomet, Kenya. Program development phases included (1) cardiovascular care provided by 1 full-time US board-certified cardiothoracic surgeon; (2) short-term volunteer surgical teams from the United States and Canada; and (3) development of a cardiothoracic residency program based on the Society of Thoracic Surgeons training curriculum. Patient demographics and outcomes were analyzed throughout each phase of program development. Results: A total of 817 cardiac procedures were performed during the study period, including 236 congenital (28.8%) and 581 adult (71.1%) procedures. Endemic rheumatic valvular heart disease predominated (581 patients, 62.3%). Local surgical team case volume grew over the study period, overtaking visiting team volume in 2019. Perioperative mortality was 2.1% and consistent between the visiting teams and the locally trained teams. Surgical training via a 3-year cardiothoracic residency is now in its fourth year, with the 2 graduates now retained as full-time teaching staff. Conclusions: Global health partnerships have the potential to address unmet needs in cardiac care within low- and middle-income countries. These data support the concept that acceptable clinical outcomes and consistent growth in volume can be achieved during the transition toward fully independent cardiac surgical care.

Prevalence of esophageal squamous dysplasia in relatives of patients with esophageal cancer in Southwestern Kenya.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) and its asymptomatic precursor lesion, esophageal squamous dysplasia (ESD), are common in East Africa. It is unknown whether family history of esophageal cancer is a risk factor for both ESD and ESCC in Africa, and whether family members of affected persons should be screened. METHODS: We recruited 296 asymptomatic adult first-degree relatives of ESCC patients residing in southwestern Kenya. Participants completed questionnaires and underwent endoscopy with Lugol's iodine staining and biopsy to determine the prevalence of ESD. Prevalence comparisons were made with a prior population-based cohort from the same catchment area who also underwent Lugol's chromoendoscopy. RESULTS: Mean age was 40.7 years, compared to 62.7 years in the prior population study. The overall prevalence of ESD/ESCC among first-degree relatives was 14.7%, comparable to the background population prevalence of 14.4%, and this comparability remained even after adjusting for the different age distributions of the studies. Post-primary education was the only measured variable that was associated with a decreased risk of ESD/ESCC (adjusted OR=0.31, 95% CI: 0.11, 0.83). There was heterogeneity in the ESD prevalence across families, even after adjustments for varying age and other measured factors. CONCLUSIONS: The prevalence of esophageal squamous dysplasia among first-degree relatives of persons with ESCC was similar to that of the background population of southwestern Kenya; however, there was heterogeneity in ESD prevalence between families, suggesting other genetic or environmental factors may influence family prevalence. Further study of families with a high prevalence of ESD or ESCC is justified.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. METHODS: This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. DISCUSSION: This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. TRIAL REGISTRATION: This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393 .

An Online, Modular Curriculum Enhances Surgical Education and Improves Learning Outcomes in East, Central, and Southern Africa: A Mixed-Methods Study.

Objective: We aimed to determine the impact of a standardized curriculum on learning outcomes for surgical trainees in East, Central, and Southern Africa (ECSA). Background: As surgical education expands throughout ECSA, there is a recognized need for a standardized curriculum. We previously described the design of a novel, large-scale, flipped-classroom, surgical curriculum for trainees in ECSA. Methods: In January 2020, the first year of curricular content for trainees of the College of Surgeons of ECSA was released, containing 11 monthly thematic topics, each with 2 to 5 weekly modular subtopics. We aimed to evaluate 3 outcomes utilizing data sources incorporated into the curriculum structure. Learner engagement was assessed by the number of trainees completing curriculum topics. User experience was evaluated using quantitative and qualitative feedback responses to embedded surveys for each content week. Curriculum impact on trainee examination performance was assessed by comparing certification examination scores stratified by the number of curricular topics each trainee completed. Results: Two hundred seventy-one trainees (96%) in 17 countries accessed at least 1 weekly module. Trainees completed a median of 9 topics (interquartile range: 6-10). The feedback survey response rate was 92% (5742/6233). Quantitative and qualitative responses were positive in overall module value (93.7% + 2.6%), amount of learning experienced (97.9% + 1.4%), confidence in achieving learning objectives (97.1% + 2.4%), and ease of use of the module (77.6% + 5.98%). Topic-related certification examination performance improved significantly with increased completion of thematic topics. Conclusions: A standardized surgical curriculum in ECSA demonstrated excellent trainee usage, positive feedback, and improved examination scores.

Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Indoor wood combustion, carcinogenic exposure and esophageal cancer in southwest Kenya.

BACKGROUND: Exposure to polycyclic aromatic hydrocarbons (PAHs) is a risk factor for esophageal squamous cell carcinoma (ESCC) in high-incidence areas of China, Iran and Brazil, but PAH assessments have not been conducted in East Africa, another ESCC hot spot. OBJECTIVE: To evaluate demographic or lifestyle factors associated with the PAH biomarker concentrations in the study population, and whether PAH metabolite concentrations showed any associations with esophageal precancerous lesions. METHODS: We recruited a community-based sample of 289 asymptomatic adults from a rural area of Kenya and performed Lugol's chromoendoscopy to detect esophageal squamous dysplasia (ESD); participants completed a questionnaire and provided a spot urine specimen. We analyzed urine for seven hydroxylated metabolites of naphthalene, fluorene, phenanthrene, and pyrene at the U.S. National Center for Environmental Health, and compared creatinine-corrected PAH metabolite concentrations with questionnaire data and the presence of ESD. RESULTS: PAH metabolite concentrations among never tobacco users in these rural Kenya residents were 2.4-28.1 times higher than those reported from never tobacco users in Iran, Brazil and the USA. Female sex, cooking indoors, having no post-primary education, and age <50, but not tobacco use, were positively and significantly associated with PAH metabolite concentrations. Almost all participants used wood as cooking fuel. Nine participants had advanced ESD. Adjusted logistic regression showed a significant association between 2-hydroxynaphthalene (OR = 4.19, 95%CI: 1.01-17.47) and advanced ESD. All other PAH metabolites had positive but non-significant associations with advanced ESD. CONCLUSIONS: Urinary PAH metabolite concentrations among never tobacco users are markedly higher in this group from Kenya than in other populations and are associated with indoor cooking with wood on open, unvented stoves. These metabolite concentrations were also associated with the presence of advanced esophageal dysplasia. Our findings underline the importance of assessing alternative cooking conditions to reduce PAH exposure in this population.

Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy.

PURPOSE: The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. METHODS: In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. RESULTS: Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. CONCLUSION: The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.

Surgical Simulation in East, Central, and Southern Africa: A Multinational Survey.

BACKGROUND: High-income countries have increased the use of simulation-based training and assessment for surgical education. Learners in low- and middle-income countries may have different educational needs and levels of autonomy but they and their patients could equally benefit from the procedural training simulation provides. We sought to characterize the current state of surgical skills simulation in East, Central, and Southern Africa and determine residents' perception and future interest in such activities. METHODS: A survey was created via collaboration and revision between trainees and educators with experiences spanning high-income countries and low- and middle-income countries. The survey was administered on paper to 76 trainees (PGY2-3) who were completing the College of Surgeons of East, Central, and Southern Africa (COSECSA) Membership of the College of Surgeons examination in Kampala, Uganda in December 2019. Data from paper responses were summarized using descriptive statistics and frequencies. RESULTS: We received responses from 43 trainees (57%) from 11 countries in sub-Saharan Africa who participated in the examination. Fifty-eight percent of respondents reported having dedicated space for surgical skills simulation training, and most (91%) had participated in some form of simulation activity at some point in their training. However, just 16% used simulation as a regular part of training. The majority of trainees (90%) felt that surgical skills learned in simulation were transferrable to the operating room and agreed it should be a required part of training. Seventy-one percent of trainees felt that simulation could objectively measure technical skills, and 73% percent of respondents agreed that simulation should be integrated into formal assessment. However, residents split on whether proficiency in simulation should be achieved prior to operative experience (54%) and if nontechnical skills could be measured (51%). The most common cited barriers to the integration of surgical simulation into residents' education were lack of suitable tools and models (85%), funding (73%), and maintenance of facilities (49%). CONCLUSIONS: Residents from East, Central, and Southern Africa strongly agree that simulation is a valuable educational tool and ought to be required during their surgical residency. Barriers to achieving this goal include availability of affordable tools, adequate funding and confidence in the value of the educational experience. Trainees affirm further efforts are necessary to make simulation more widely available in these contexts.

Optimal management of esophageal cancer in Africa: A systemic review of treatment strategies.

Esophageal cancer (EC) is a leading cause of cancer morbidity and mortality in Africa. Despite the high burden of disease, optimal management strategies for EC in resource-constrained settings have yet to be established. This systematic review evaluates the literature on treatments for EC throughout Africa and compares the efficacy and safety of varying treatment strategies in this context (PROSPERO CRD42017071546). PubMed, Embase and African Index Medicus were searched for studies published on treatment strategies for EC in Africa from 1980 to 2020. Searches were supplemented by examining bibliographies of included studies and relevant conference proceedings. Methodological quality/risk of bias was assessed using the Cochrane Risk-of-Bias tool and the Newcastle-Ottawa Scale. Forty-six studies were included. Case series constituted the majority of studies: 13 were case series reporting on outcomes of esophagectomies, 17 on palliative luminal or surgical interventions, four on radiotherapy and three on concurrent chemoradiation. Nine randomized controlled trials were identified, of which four prospectively compared different treatment modalities (one investigating radiotherapy vs chemoradiation, three evaluating rigid plastic stents vs other treatments). This review summarizes the research on EC treatments in Africa published over the last four decades and outlines critical gaps in knowledge related to management in this context. Areas in need of further research include (a) evaluation of the safety and efficacy of neoadjuvant therapy in patients with locally advanced disease; (b) strategies to improve long-term survival in patients treated with definitive chemoradiation; and (c) the comparative effectiveness of modern palliative interventions, focusing on quality of life and survival as outcome measures.

Referral Patterns of Burn Injury in Rural Kenya.

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19-2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.

Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya.

BACKGROUND: The education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee's performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees' abilities. MATERIALS AND METHODS: At a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability. RESULTS: There were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning. CONCLUSIONS: Between trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.

Assessing Post-operative Pain with Self-reports via the Jerrycan Pain Scale in Rural Kenya.

BACKGROUND: Perioperative pain management is an essential component to improving patient outcomes. Measurement and description of pain are challenging and vary in different contexts. The objective of this study was to assess the utility of self-reporting via visual analogue scales using the Jerrycan visual analogue scale in the assessment of post-operative pain and to validate the use of this novel scale compared to standard pain scales. MATERIALS AND METHODS: Two hundred and forty-one inpatients who underwent surgical procedures were prospectively assessed for post-operative pain over a 12-month period from February 2016 to January 2017. Participants included patients who underwent general surgery, orthopedic and obstetrics/gynecology procedures. On post-operative day one, four scales were assessed: Verbal scale, Hands scale, Faces scale and Jerrycan scale, each ranging from 0-5. Scores for each scale were recorded, and agreements between scales were calculated using kappa values and Spearman's rank coefficients. RESULTS: The mean age was 34.8 years and more female subjects were evaluated (68%). The majority received spinal anesthesia (61%). The mean pain score was 2.5 for all scales. The Jerrycan (0.50) and Faces scales (0.43) had moderate agreements with the Verbal scale. Participants preferred the Jerrycan Pain Scale. CONCLUSION: The Jerrycan pain scale had comparable scores and reasonable agreement with 3 other pain scales among a cohort of post-operative patients. Patient preference and ease of use of the Jerrycan scale may impact assessment and management of pain in a rural African setting. This scale may be adapted for use in similar resource settings for post-operative pain management.

Operative Case Volume Minimums Necessary for Surgical Training Throughout Rural Africa.

BACKGROUND: Resident operative case volumes are an important aspect of surgical education, and minimums are required in Accreditation Council for Graduate Medical Education (ACGME) programs. Minimum operative case volumes for training do not exist in rural Africa. Our objective was to determine the optimal minimum operative case volume necessary for general surgery training in rural Africa. METHODS: A cross-sectional census electronic survey was conducted among faculty (N = 24) and graduates (N = 56) of Pan-African Academy of Christian Surgeons training programs. Three equally weighted exposures (median minimum case volume suggested by participants, operative experience of prior graduates, and comparisons with ACGME minimums), adjusted from responses to targeted questions, were utilized to construct an optimal minimum operative case volume for training. RESULTS: Sixty-four surgeons were contacted and 40 (13 faculty, 24 graduates, and 3 graduates who became faculty) participated. All participants thought operative case minimums were necessary, and the majority (98%) felt current training adequately prepared surgeons for their setting. Constructed optimal case volumes included 1000 major cases with fewer required cases than ACGME in abdomen, breast, thoracic, vascular, endoscopy, and laparoscopy and more required cases than ACGME for alimentary tract, endocrine, operative trauma, skin and soft tissue, pediatric, and plastic surgery. Other categories (gynecology, orthopedics, and urology) were deemed necessary for surgical training, with regional differences. Prior graduates satisfied the overall, but not category-specific, proposed minimums. CONCLUSIONS: The surveyed surgeons highlighted the need for diverse surgical training with minimum exposures. They described increased need for cases reflecting regional variations with a desire for more experience in categories less common at their institutions.

Curative Surgery Improves Survival for Colorectal Cancer in Rural Kenya.

BACKGROUND/AIMS: Colorectal cancer (CRC) is increasing in low- and middle-income countries. Surgical care is essential for the treatment. Many patients do not have access to curative surgery for colorectal cancer in rural Kenya. To better understand the impact of surgical care on colorectal cancer in a resource-limited setting, we compared the experience of patients undergoing operations to those who did not. METHODS: All patients with histologically confirmed CRC at Tenwek Hospital from January 1, 1999, to December 31, 2017, were reviewed. Demographic and clinical data were extracted from records when available. The exposure was either curative operation, palliative operation, or no operation. The primary outcome was survival at 5 years, assessed with Cox proportional hazard analysis after propensity-score matching for age, sex, tumor site, time period, and stage. RESULTS: One hundred and sixty-five patients were identified on chart review. Survival information was available for 150 patients with a median follow-up of 319 days. Fifty-two percent had colon cancer and 48% had rectal cancer. At diagnosis, the mean age was 55.4 years (SD: 16.7) and the male to female ratio was 1.1:1. Thirty-nine percent underwent curative operations, 25% palliative operations, and 36% no operations. One-year survival was estimated to be 98% for curative surgery, 73% for palliative surgery, and 83% for no surgery (p = 0.0005). On crude analysis, 5-year survival improved with curative operation in comparison to no operation with a hazard ratio of 0.30 (CI: 0.14-0.64) (p = 0.002). After propensity matching, the hazard ratio for curative operation versus no operation remained significant, 0.34 (CI: 0.14-0.80) (p = 0.01). CONCLUSIONS: Curative surgery improves survival in our resource-limited environment. Although various factors contribute to the use of surgical treatment, the survival advantage persists after adjusted analysis. Barriers exist for access to prompt surgical evaluation and treatment. Surgical care should be a priority to address the increasing burden of CRC in resource-limited settings.

Investigating tea temperature and content as risk factors for esophageal cancer in an endemic region of Western Kenya: Validation of a questionnaire and analysis of polycyclic aromatic hydrocarbon content.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is common in certain areas worldwide. One area, western Kenya, has a high risk of ESCC, including many young cases (<30 years old), but has limited prior study of potential risk factors. Thermal injury from hot food and beverages and exposure to polycyclic aromatic hydrocarbons (PAHs) have been proposed as important risk factors for ESCC in other settings. The beverage of choice in western Kenya is milky tea (chai). METHODS: Healthy individuals >18 years of age who were accompanying relatives to an endoscopy unit were recruited to participate. The preferred initial temperature of chai consumption in these adults was measured by questionnaire and digital thermometer. Comparisons of these results were assessed by kappa statistics. Concentrations of 26 selected PAHs were determined by gas chromatography/mass spectrometry in samples of 11 brands of commercial tea leaves commonly consumed in Kenya. RESULTS: Kappa values demonstrated moderate agreement between questionnaire responses and measured temperatures. The mean preferred chai temperatures were 72.1 °C overall, 72.6 °C in men (n = 78), and 70.2 °C in women (n = 22; p < 0.05). Chai temperature did not significantly differ by age or ethnic group. The PAH levels in the commercial Kenyan tea leaves were uniformly low (total PAH < 300 ng/g of leaves). CONCLUSIONS: Study participants drink chai at higher temperatures than previously reported in other high-risk ESCC regions. Chai is not, however, a source of significant PAH exposure. Very hot chai consumption should be further evaluated as a risk factor for ESCC in Kenya with the proposed questionnaire.

The African Esophageal Cancer Consortium: A Call to Action.

Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer-related death; however, worldwide incidence and mortality rates do not reflect the geographic variations in the occurrence of this disease. In recent years, increased attention has been focused on the high incidence of esophageal squamous cell carcinoma (ESCC) throughout the eastern corridor of Africa, extending from Ethiopia to South Africa. Nascent investigations are underway at a number of sites throughout the region in an effort to improve our understanding of the etiology behind the high incidence of ESCC in this region. In 2017, these sites established the African Esophageal Cancer Consortium. Here, we summarize the priorities of this newly established consortium: to implement coordinated multisite investigations into etiology and identify targets for primary prevention; to address the impact of the clinical burden of ESCC via capacity building and shared resources in treatment and palliative care; and to heighten awareness of ESCC among physicians, at-risk populations, policy makers, and funding agencies.

Cross sectional study of serum selenium concentration and esophageal squamous dysplasia in western Kenya.

BACKGROUND: Low serum selenium status has been associated with increased risk of esophageal squamous cell carcinoma (ESCC). East Africa is a region of high ESCC incidence and is known to have low soil selenium levels, but this association has not previously been evaluated. In this study we assessed the association of serum selenium concentration and the prevalence of esophageal squamous dysplasia (ESD), the precursor lesion of ESCC, in a cross-sectional study of subjects from Bomet, Kenya. METHODS: 294 asymptomatic adult residents of Bomet, Kenya completed questionnaires and underwent endoscopy with Lugol's iodine staining and biopsy for detection of ESD. Serum selenium concentrations were measured by instrumental neutron activation analysis. Odds ratios (OR) and confidence intervals (95% CI) for associations between serum selenium and ESD were calculated using unconditional logistic regression. RESULTS: The mean serum selenium concentration was 85.5 (±28.3) µg/L. Forty-two ESD cases were identified (14% of those screened), including 5 (12%) in selenium quartile 1 (Q1), 5 (12%) in Q2, 15 (36%) in Q3, and 17 (40%) in Q4. Higher serum selenium was associated with prevalence of ESD (Q4 vs Q1: OR: 3.03; 95% CI: 1.05-8.74) and this association remained after adjusting for potential confounders (Q4 vs Q1: OR: 3.87; 95% CI: 1.06-14.19). CONCLUSION: This is the first study to evaluate the association of serum selenium concentration and esophageal squamous dysplasia in an African population at high risk for ESCC. We found a positive association between higher serum selenium concentration and prevalence of ESD, an association contrary to our original hypothesis. Further work is needed to better understand the role of selenium in the etiology of ESCC in this region, and to develop effective ESCC prevention and control strategies.