Evaluation of Colorectal Cancer Management in Eastern DR Congo. About 55 Cases Were Collected from January 2002 to December 2016 Panzi General Referral Hospital ()
1. Introduction
Colorectal cancer (CRC) is a malignant proliferation affecting the epithelial and connective constituents of the colon and rectum [1] . It is the most common digestive cancer in both sexes and the second leading cause of cancer-related death in Western countries [2] . Although rare, it affects a high proportion of young people in Black Africa [3] . Diagnosis is often facilitated by low endoscopy, which allows for biopsy samples to be taken [4] . In the early stages, symptoms of colorectal cancer are often discreet and consist mainly of transit disorders and lower digestive hemorrhage [5] [6] . Surgical management is essential [7] . Despite the progress made in detecting and managing the disease, the prognosis remains poor, with a survival rate of no more than 50% at 5 years [8] . The risk of developing colorectal cancer before the age of 75 is 3.5% in the general population [9] . In France, it is the most common cancer in both sexes. Colorectal cancer is the most common digestive cancer, accounting for 53.8% of cases in men and 68.5% in women. The sex ratio is 1.5 [10] . The average age of onset is around 70 years, and the incidence is rare before the age of 50 (<6%) [5] . In Africa, colorectal cancers are relatively uncommon, representing only 1% - 3% of all cancers. The age of onset is young, with an average of 46 years [11] . In Burkina Faso, colorectal cancers affect a relatively young population and appear to be rare [12] . In Congo Brazza, CRC accounts for 30.2% of all digestive tract cancers [13] . In the Democratic Republic of Congo, approximately 70% of the population lives below the poverty line [14] .
Unfortunately, there is no national CRC database available to understand the epidemiology of cancers in our country and manage them early. The lack of a cancer registry results in an underestimation of the incidence [15] , which poses a problem for managing patients who appear to be younger than those in developed countries.
Does low socio-economic status affect the development and management of colorectal cancer in South Kivu?
This study aims to present the current state of knowledge by describing the epidemiological, diagnostic, and therapeutic features of colorectal cancers in our environment.
The specific objectives were:
1) To describe the characteristics of patients with colorectal cancer.
2) To determine the prevalence of colorectal cancer in our population.
3) To describe the type of colorectal cancer and the symptoms at diagnosis and the therapeutic context.
4) To facilitate the establishment of a cancer registry by providing some recommendations.
In this study, we aimed to identify the specificities of managing colorectal cancer in resource-limited settings and to introduce new tools for detecting its prevalence. It is important to raise awareness that colorectal cancer is not exclusively a cancer affecting older individuals.
2. Materials and Methods
This is a retrospective descriptive study based on the archives of the endoscopy departments, pathology laboratory, operating theater, and inpatient wards of Panzi General Referral Hospital, which serves as a training hospital for general practitioners and specialists from the Evangelical University in Africa, located in the eastern part of the Democratic Republic of Congo.
This study included all cases of primary colorectal cancer that were histologically confirmed on biopsies or surgical specimens between January 2002 and December 2016.
Files without information on the histopathological nature of the digestive tract tumor or where the histopathological diagnosis had not been established were excluded.
The study analyzed epidemiological, clinical, and therapeutic variables including age, sex, socioeconomic status, profession, origin, symptoms, mode of admission, histological characteristics, topography, surgical context, surgical technique, and evolution.
The data was collected in Excel 2010 and analyzed using Epi info version 3.5.4 and JMP software to calculate the percentage frequency of each parameter and chi-square. The analysis started with a description of the data using standard descriptive statistics, including the calculation of the mean and standard deviation. Next, we conducted a bivariate analysis to identify any association between the dependent and independent variables. We used Student’s T-test or the chi-squared or Ficher test if the conditions for their application were met.
The statistical significance level was set at 5% (p < 0.05).
The index of socio-economic position (IPSE) was utilized to estimate the socio-economic level, based on the formula:
IPSE = age − 6 × NF − 4 × CP + 55, where NF represents the level of education and CP represents the professional category. The constant 55 is added to obtain positive values [16] .
The results are presented in Table 1.
3. Results
3.1. Prevalence of Colorectal Cancer
This study collected 55 cases of colorectal cancer from a population of 129 patients with digestive tract cancer in the surgical department of the Panzi HGR. The prevalence of colorectal cancer was 42.6%.
3.2. Epidemiological and Clinical Aspects
Male prevalence was 69.1% and sex ratio was 2.2. The mean age was 50.8 years, ranging from 20 to 81 years. The socioeconomic status was low in 69.1% of the cases, and the diagnostic delay was over 6 months in 72.7% of the cases. Unemployment was reported in 47.3% of the cases, and 61.7% of the patients came from rural areas. CRC was diagnosed due to rectal bleeding in 49.1% of the cases, and it was predominantly discovered in an emergency setting in 69.1% of the cases.
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Table 1. shows the distribution of colorectal cancers by sex, age group, socioeconomic level, occupation, origin, diagnostic delay, symptoms, and mode of discovery.
3.3. Diagnostic and Therapeutic Aspects
Table 2 shows that 58.20% of the colorectal cancer (CRC) cases were diagnosed by an initial endoscopy of the lower colon.
Adenocarcinoma was present in 94.5% of cases, with 58.2% located in the rectum.
All patients underwent surgical treatment, with 5.5% receiving adjuvant chemotherapy. Of those, 45.5% underwent abdominoperineal amputation, and 54.5% experienced postoperative complications. Unfortunately, 25.5% of patients died.
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Table 2. Distribution according to diagnostic circumstance, topography, histology, extension, treatment, surgical context, type of operation, morbidity, and evolution.
3.4. Correlation between Evolution and Gender, Standard of Living, and Type of Intervention
The table indicates that 78.6% of the deaths were male. The statistical test suggests that there is no dependence between gender and the development of colorectal cancer, as the Fisher exact is 0.2959 above the significance threshold but with a relative risk of 1.6404 (Table 3).
More than three-quarters of the deaths had a low socioeconomic standard of living, but there was no correlation between socioeconomic level and colorectal cancer progression.
There was no statistically significant correlation between the type of operation and outcome, although abdominoperineal amputation was performed in 64.3% of patients who died.
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Table 3. Breakdown of evolution by gender, standard of living, and type of intervention.
4. Discussion
In this study, colorectal cancer accounted for 42.6% of all digestive tract cancers, ranking second after gastric cancer. These results are consistent with those of Chbani L et al., who reported a high frequency of colorectal cancers at 41.43% of all digestive tract cancers, followed by gastric cancers at 29.64% [17] . In a retrospective study from 1992 to 2009, Salamatou MG et al. found that the prevalence of colorectal cancer in Niger was 28.80%, which ranked second after gastric cancer [18] .
The study also revealed a male predominance of 69.1% with a sex ratio of 2.2. These findings are consistent with those of Peko et al. [13] , who reported a male/female sex ratio of 1.5. In a study by Tebibel Soraya et al. [19] , males accounted for 66.36% of the cases, with a sex ratio of 1.9, which is similar to the present study. This male predominance in our environment may be due to greater male exposure to risk factors such as alcohol, tobacco, and a low-fiber diet (barbecues).
Colorectal cancer was found to occur at a younger age than reported in the literature. The mean age at diagnosis in this study was 50.8 years with a standard deviation of ±16.4 years and extremes of 20 and 81 years. This is significantly lower than the mean age of 65 - 75 years reported in Western literature [20] . The occurrence of colorectal cancers at a young age in our series may be attributed to a hereditary aspect, possibly through consanguinity.
The life expectancy of Africans, including Congolese, is significantly lower than that of European populations.
Over half of Africa’s population, including the DRC, is young, with a large proportion under the age of 50.
In a retrospective study conducted by Tebra et al. in Tunisia, 165 cases of rectal cancer were collected and treated at the radiotherapy department of CHU Sousse between 1995 and 2004. The mean age at diagnosis was 56 years, with a range of 26 to 86 years [21] .
In this series, patients under the age of 40 accounted for 27.3% of all colorectal cancer patients. In Western countries, such as the United States, colorectal cancer in young people accounts for only 1% to 4% of all cases [22] . Colorectal cancer is more prevalent in young people in Middle Eastern countries, with rates of In Türkiye, the percentage is 18% [23] , while in Egypt it is 38%. In Egypt, the high incidence of colorectal cancer in young people is mainly attributed to the natural distribution of the age pyramid, as only 5.70% of the population is over 60 years old [24] . Additionally, a study of 165 cases of rectal cancer in central Tunisia by Tebra et al. showed that 70% of patients had an average socioeconomic level [21] . Disadvantaged patients have a higher frequency of emergency admissions for complicated colorectal cancer compared to non-disadvantaged patients (56% vs 35%, odd ratio: 2.29) [25] . The study found that the unemployed and housewives were the most represented at 47.3%, which may be related to their higher representation in the general population. Additionally, socioeconomic and educational levels are generally low among disadvantaged patients, leading them to resort to traditional treatments and self-medication.
In a study on the epidemiology of digestive cancers in hospitals in Bamako, Diarra et al. [26] found that housewives and farmers were the most represented social strata, accounting for 34.8% and 33% respectively. These results are partially consistent with those of Diarra et al. [26] . The study also revealed that 61.7% of patients came from rural areas. Similarly, Hama et al.’s study in Niger showed that half of the patients came from disadvantaged backgrounds [6] . In 72.7% of cases, the delay between the appearance of the first sign and the histological diagnosis was over 6 months. The mean delay was 9.9 months, with extremes ranging from 1 to 23 months and a standard deviation of 5.3. This delay is likely linked to poverty, as this cancer is more prevalent among underprivileged social classes who accumulate risk factors. In Africa, and specifically in DR Congo, diagnosis is often made at an advanced stage of the disease.
Tebra et al. reported an average consultation time of 8 months [21] , which is consistent with this series. In the study by Pocard M et al., the average consultation time was less than or equal to 6 months in 73% of cases, with an average of 4.7 months (range: 0 - 20 months) [27] . The most common symptom of colorectal cancer was rectal discharge (49.1%). In a study conducted by Casanelli et al. at Treichville University Hospital in Côte d’Ivoire, which focused on the epidemiological, clinical, and therapeutic aspects of 16 cases, rectorrhagia was the dominant clinical symptom in 43.75% of cases [28] . This percentage is slightly lower than the findings of the current study. In contrast, Tebra et al. found that rectorrhagia was the dominant symptom in 82.0% of cases [21] , which is significantly higher than the current study.
Colorectal cancer was discovered through emergency means in 69.1% of cases, with intestinal obstruction being the mode of discovery in 27.3% of cases. These findings are consistent with those of Laforest A et al., who reported that left colonic tumors are revealed through intestinal obstruction in nearly 20% of cases [29] . According to Casanelli et al. (28), bowel obstruction was a mode of discovery of colorectal cancer in 6.25% of cases. All patients underwent an endoscopic examination, with 58.2% of cases confirmed during the initial endoscopy and 41.8% discovered intraoperatively.
In this study, 58.2% of the cancers were in the rectum. A study by Sawadogo et al. in Burkina Faso showed that rectal localization of colorectal cancer was predominant at 58.8%, which is consistent with this study.
Adenocarcinoma was the most frequent histological type, accounting for 94.5% of cases. The proportion of cases with adenocarcinoma is consistent with previous literature, which estimates it to be between 95% and 97% [30] . Soraya T et al. found a similar figure of 94.54% [19] . In Tebra et al.’s series, adenocarcinoma was found in 96.40% of cases [21] .
Abdominal ultrasounds and chest X-rays were performed in all cases, revealing peritoneal adenopathy in 16.4% of ultrasounds, liver metastases in 21.8% of ultrasounds, and lung metastases in 7.3% of chest X-rays.
In the study conducted by Tebra et al., abdominal ultrasound was performed in 97.5% of cases and chest radiography was performed in 100% of cases. The study also found that at the time of diagnosis, 45.5% of colorectal cancer patients had synchronous metastases, which is consistent with previous literature reporting that nearly half of patients develop metastases [31] . Of those cases, 5.5% were found to be immediately metastatic [21] . Additionally, Casanelli et al. reported that pulmonary metastases were found in 6.25% of cases [28] . All patients in this series underwent surgery, with only 5.5% receiving adjuvant chemotherapy. A study conducted by Hama Y et al. in Niger on Rectal cancer and poverty: a medical divide, showed that 11.1% of patients underwent adjuvant chemotherapy alone [6] . The first surgical technique used was abdominoperineal amputation, which accounted for 45.5% of cases. It was indicated for curative purposes in most cases of cancer of the lower and middle rectum. In the Tunisian series by Tebra et al. [21] , colorectal cancer represented 41.30% of cases. Among these patients, 54.5% experienced various postoperative complications and 25.5% died. Cossa and Club Coelio conducted a study on laparoscopic colorectal resection in elderly patients, which included 144 participants. The study found a morbidity rate of 29% and a mortality rate of 6%. These rates were significantly higher in patients with cancerous or psychiatric pathology or those living in long-stay facilities [32] . On average, 43 deaths from colorectal cancer per 100 new cases are recorded in Poitou-Charentes every year, with 55% of those being male [33] .
In this series, 78.6% of deaths were male. In Bouffard B et al.’s study on colorectal cancer incidence and mortality in Poitou-Charentes, 55% of deaths were male [33] .
In this series, 64.3% of patients who died underwent abdominoperineal amputation. The Norwegian Cancer Registry reports a 30% increased risk of death in patients treated with abdominoperineal amputation compared to those treated with prior resection [34] . This difference may be due to late consultations and the context of operability, which was dominated by extreme urgency.
5. Conclusion
Colorectal cancer is a prevalent disease in our environment, affecting both genders but with a higher incidence in males. It is often detected through lower gastrointestinal bleeding and is usually accompanied by complications. Unfortunately, diagnosis is often delayed. The only available treatment option in our environment is surgical removal of the tumor. To enhance the management of colorectal cancers, it would be beneficial to implement early detection of cancers in the population through the primary healthcare system. This would enable the creation of a registry of cancers and their incidence in our region.