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South African Journal of Surgery

On-line version ISSN 2078-5151
Print version ISSN 0038-2361

S. Afr. j. surg. vol.57 n.2 Cape Town Jun. 2019




Oesophageal cancer in South Africa: the need for a public health response



E LootsI; L FerndaleII; DL ClarkeII

IPrivate Practice, Entabeni Hospital, Durban
IIDepartment of Surgery, Grey's Hospital, Pietermaritzburg, University of KwaZulu-Natal




This edition of the South African Journal of Surgery has chosen to focus on oesophageal cancer. This is timely and appropriate as there has been a general paucity of research on this common and lethal cancer over the last two decades.1 The outcomes for oesophageal cancer in South Africa remain abysmal and lag behind those reported in the developed world.2,3,4 The three papers in this edition highlight the fact that the quality of care and treatment of this disease is extremely variable across South Africa. There is a difference in algorithms of care and in clinical outcomes of this disease between the Western Cape and the Eastern Cape.5 These discrepancies also exist between private and state sectors.6 For example, there appears to be very little detection of premalignant disease in the state sector but a reasonable rate in the private sector. The result as documented in the third paper is that patients present late with advanced disease and are only candidates for palliation.7 It would appear that the management of gastrointestinal malignancy in South Africa is fragmented and ad hoc and outcomes remain less than ideal. There are a number of reasons for this failure to develop a comprehensive strategy. The focus of the department of health over the last twenty five years has been a primary health care one and has been directed at infectious disease and maternal and child health. This has resulted in a relative neglect of diagnostic and curative services.8 However, there has also been a broad failure by the medical fraternity to take on board the concept of a comprehensive strategy. As the demographics of South Africa continue to change, so the burden of cancer and other non-communicable diseases become apparent. The challenge is to avoid fatalism by responding with a coordinated plan. Increasingly it is clear that a public health type approach is applicable to non-communicable diseases. A public health approach integrates the various components of a comprehensive health strategy. These range from prevention and education, to earlier detection followed by appropriate multi-disciplinary treatment. This can be curative or palliative and includes rehabilitative treatment. A good example of such an approach is the trauma systems approach pioneered by the American College of Surgeons. This template can be applied to non-communicable diseases. Modern gastrointestinal cancer care is multi-disciplinary and multi-modal. Such a disease requires a co-ordinated systematic response. Surgery is one component of the care of patients with cancer and for it to be effective, surgical care must be delivered as part of a comprehensive public health-based strategy. It is hoped that this edition will encourage the development of a multi-disciplinary interest group which will develop strategies to improve the detection and referral of patients with oesophageal cancer and to promote consistent national algorithms and guidelines for this disease. Only by developing a comprehensive strategy will we have any hope of controlling and rolling back this disease.

Conflicts of interest

The authors declare no conflicts of interest.



1. Loots E, Sartorius B, Madiba TE, Mulder CJ, Clarke DL. Is clinical research in oesophageal cancer in South Africa in crisis? A Systematic Review. World J Surg. 2017 Mar;41(3):810-816. doi: 10.1007/s00268-016-3778-5.         [ Links ]

2. Govender M, Ferndale L, Clark DL. Oesophageal cancer in South Africa: The long timeline from onset of symptoms to definitive management. S Afr J Oncol. 2017;1(0), a6.        [ Links ]

3. Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet. 2013 Feb 2;381(9864):400-12. doi: 10.1016/S0140-6736(12)60643-6.         [ Links ]

4. Loots E, Anderson F, Clarke DL, Mulder CJ, Madiba TE. Self-expandable metal stents in esophageal cancer in a high HIV prevalence area: A survival analysis and evaluation of prediction scores Surg Laparosc Endosc Percutan Tech. 2016 Dec;26(6):455-458.         [ Links ]

5. Nel D, Omar M, Chinnery G, Jonas E. West vs. East - disparity in oesophageal cancer management in South Africa - a comparison between two tertiary centres with special focus on the palliation of dysphagia. SA J Surg 2019;57:10-15        [ Links ]

6. Clarke DL, Lutakwa A, Loots E, Loots E, Smith M. A comparison of oesophageal cancer in the public sector and the private sector in KwaZulu-Natal. SA J Surg 2019;57:16-19        [ Links ]

7. Ferndale L, Sartorius B, Aldous C, Thomson SR. Oesophageal cancer in Area 2 of Kwazulu-Natal, South Africa. Indicators of late presentation. SA J Surg 2019;57:4-9        [ Links ]

8. Loots E, Clarke DL, Newton K, Mulder CJ. Endoscopy services in KwaZulu-Natal Province, South Africa, are insufficient for the burden of disease: Is patient care compromised? S Afr Med J. 2017 Oct 31;107(11):1022-1025. doi: 10.7196/SAMJ.2017.v107i11.12484.         [ Links ]



Damian Clarke

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