At least 100 people succumb to cancer of the oesophagus in Kakamega county every year, according to the records at Kakamega Cancer Centre.
The number of men suffering from the disease is higher than that of women, the centre at Kakamega Teaching and Referral Hospital also indicates.
It links the prevalence to genetic and environmental factors, such as contamination of food by mycotoxins and pesticides, consumption of traditional brews like changaa and busaa, poor diet, smoking, use of firewood and genetic predisposition.
The centre's statistics indicate at least 70 per cent of throat cancer incidents in men in the region arise from smoking and excessive consumption of local brews like changaa and busaa.
Hilda Mubisi, a clinical oncologist at the centre, says cancer of the oesophagus is among the commonest cancers treated at the facility and is highly prevalent in both genders, with men recording higher numbers.
Mubisi says in trying to establish the risk factors causing the spike in this particular cancer, they study each patient’s history.
“Once a patient is diagnosed with cancer of the oesophagus, we try to ascertain exactly the conditions that may have predisposed them to the disease,” she says.
They look at the patient’s diet as well as the environment they live in; for instance, the type of fuel they use at home.
“We want to know if they use firewood, which exposes them to a lot of smoke; if they smoke tobacco and for how long they have been at it; if they drink those changaa and busaa brews and for how long; and if they constantly use hot beverages,” she says.
RISK FACTORS
The centre also looks at the patient’s close family history to ascertain if cancer runs in the family.
“This can be any other cancer and not necessarily oesophagus cancer as it still explains why one would still be predisposed to another type of cancer,” Mubisi says.
Most cancers have a genetic explanation, she says, as they start with cells that grow out of control and end up damaging the genetic predisposition.
There have been calls for more research to establish why cancer of the oesophagus is so prevalent in Kakamega.
Mubisi says most patients at the centre, especially the males, report a long-standing history of alcohol intake, especially the local changaa and busaa brews.
These brews are made from cereals like millet and maize, which are either never dried well or stored properly in dump environments, leading to their contamination with aflatoxins.
Aflatoxins are one of the carcinogens that have the potential to cause not just oesophageal cancer but also other types of cancers and non-communicable diseases.
Mubisi says this exposes the cereals to carcinogens long before the cereals are ground and used to make the brews, thus making the brews a major risk factor.
Diet has also been touted as another factor. While ugali is a staple food in most homes in Western, it could actually be the reason why some people are going to their graves early.
Mubisi says the process of harvesting and storing maize, which eventually is used to make ugali, might just explain why ugali consumers in Kakamega are bearing the brunt of oesophageal cancer.
The oncologist says poor harvesting and storage conditions of the maize cereal result in the consumption of aflatoxin-contaminated maize, with continued exposure to the toxins increasing vulnerability to the cancer.
Mubisi also points to mineral deficiencies, especially zinc, as another risk factor.
“Zinc is nutritionally important and is found in meats like beef as well as in vegetables. Those who don’t regularly don’t take these will be deficient in zinc,” Mubisi says.
While drinking hot tea is part of the culture in Western, the oncologist says more research needs to be done to find out to what extent it predisposes one to cancer of the oesophagus.
FAMILIAL CANCERS?
Genetic predisposition has also been linked to the ever-growing cases of oesophageal cancer in Kakamega.
Dismus Elkana, a medical officer at the oncology department at the Kakamega Teaching and Referral Hospital, says there is a very high probability that most active cancer cases are actually familial.
“We have had cases where a patient tells you several close family members have succumbed to one type of cancer or the other,” Elkana says.
“We have had incidents where we even found out that some of the relatives actually succumbed before they were diagnosed but had presented with all the symptoms.”
He said most challenges with diagnostics have to do with lack of equipment and infrastructure.
The officer called for more research to find out which specific risk factors are predisposing the people of Kakamega county to cancer of the oesophagus compared to other counties across Kenya.
“We don’t see such high numbers in Nyanza or central or Nairobi and the others,” he says.
“In western Kenya and especially Kakamega, the figures are worrying. We definitely need to dig deeper and find the root cause, which can only be solved via research.”
Elkana says the emphasis on research follows a trend linked to genetic predisposition captured by the Kakamega cancer centre, whereby several young patients in their 20s or 30s from the same family have suffered from or succumbed to oesophageal cancer.
“For instance, Mumias has caught our interest on this because the patients are relatively young and from the same families,” Elkana says.
“On probing, we found that close relatives had succumbed to the same. This explains a heavy genetic predisposition of this specific cancer in the family.”
He called for action on familial traits of cancer to lower the numbers.
To keep tabs on the statistics, the centre is working with health institutions at all levels to capture any pointers to the cancer, Elkana said.
In every 10 cancer cases received at the Kakamega Cancre Centre, three are cancer of the oesophagus, he said.
The centre receives a minimum of 20 cancer of the oesophagus patients in a week, with a slight predilection on the males. Minimum because more cases are undiagnosed and unreported.
POOR OUTCOMES
Elkana said the high number of fatalities has to do with the fact that many patients come in when the disease has progressed to dangerous stages.
“When they come and are newly diagnosed, we stage them first to determine which stage the cancer is at, and unfortunately, most of them are at advanced stages — stage 3 and 4 of the cancer.”
Staging determines the treatment plan and informs whether the treatment will be active or aggressive.
Elkana says the centre rarely receives stage 1 patients, but on a few lucky days, will receive stage 2 patents.
“This translates to the poor outcomes because when they come in stage 3 or 4, there is only so much we can do for them,” Elkana says.
“Whether it's chemo, radiotherapy or surgery, chances are the outcome may not be any good.”
Progress of cancer of the oesophagus is lethal and treatment, too, is equally brutal since the patient may have to be put on a combination of chemoradiotherapy.
Elkana says this can be overwhelming on the body as the patient has to deal with the cancer and its symptoms plus harsh side effects of treatment, such as vomiting and bone marrow suppression.
He explains that most patients with this particular cancer cannot feed or swallow normally as the passageway is usually blocked by the growth, and as such are not in the right condition to be put on treatment.
“So we have to find alternative ways to feed them as we ready them for the best treatment option. Treatment depends on where the cancer is,” he says.
He says since cancer of the oesophagus affects the food pipe, which is quite long, the location of the cancer determines largely the mode of alternative feeding and eventual treatment.
“If it’s more proximal or more towards the throat, we will go for gastrostomy,” he says.
Here, a tube is inserted through the skin into the stomach or the duodenum so that food is delivered externally via the tube and not the mouth as the oesophagus is blocked.
For cases where the growth is way down the oesophagus, they conduct stenting, where a tube is fixed in the oesophagus to enable food to pass.
“In this case, they swallow normally but then there is an extension tube on the food pipe to help keep the food pipe open to pass the food,” he says.
The oncologist says a major reason why many patients with cancer of the oesophagus present late at the centre is due to the nature of the disease and how the symptoms present.
While the major symptom is difficulty in swallowing, that is always the last symptom as most others are not as pronounced.
Difficulty in swallowing is normally progressive and for many, at first they will not be able to swallow solids.
As the growth increases in size, there is complete obstruction of the passageway, inhibiting even swallowing of liquids and own saliva.
“For most people, as long as they can still swallow something, it’s not an issue. That explains why some patients come late because it presents slowly. By the time they are having difficulty in swallowing, it’s reached at least stage 2,” he said.
The medical oncologist says it’s difficult to catch the disease in its earlier stages as most patients are asymptomatic, meaning they are not presenting with any symptoms pointing to the disease.
“Many people can’t go to hospital when there are no symptoms. Symptoms are the pointers to the necessary tests. Unfortunately for cancer, symptoms are signs that the disease is already progressing,” he says.
Apart from difficulty in swallowing, other common symptoms of oesophageal cancer include coughs, pain in swallowing, weight loss, low blood levels, abdominal distention and pains.
“As the stage advances, there are more symptoms since it means the cancer is spreading to other parts of the body, which brings on more symptoms,” Elkana adds.