Background:
Esophageal cancer remains a highly fatal malignancy globally and disproportionately affects populations in low- and middle-income countries, where late diagnosis and limited access to definitive treatment persist. In Malawi, population-based cancer registration and survival data remain limited, particularly in rural districts. District hospitals, therefore, offer an important lens for understanding real-world cancer outcomes and health system constraints. Phalombe District Hospital serves a predominantly rural population in southern Malawi, providing first-line inpatient care for patients with advanced malignancies.
Objectives
To describe patterns of cancer-related inpatient mortality, with a specific focus on esophageal cancer, and to identify health system factors contributing to poor short-term survival at the district hospital level.
Methods
A retrospective descriptive evaluation was conducted using ward-based mortality summary reports from female, male, and pediatric wards at Phalombe District Hospital over three years (January 2023–December 2025). Cancer-related deaths were defined as inpatient deaths with a clinician-documented primary cause of death consistent with malignant neoplasms, identified using standard clinical terminology. Esophageal cancer deaths were analysed as a distinct category. Data were aggregated by ward and year and analysed descriptively. Findings were interpreted within the context of local diagnostic capacity, referral pathways, and availability of definitive cancer management.
Results
Cancer-related deaths constituted a substantial share of inpatient mortality during the study period. Esophageal cancer was the leading cancer-related cause of death among adult inpatients, particularly in the male ward. Most patients presented with advanced disease following prolonged symptom duration, commonly with severe dysphagia and marked weight loss. Diagnostic pathways were constrained by the absence of on-site endoscopy and histopathology, resulting in predominantly clinical diagnoses. Access to definitive oncologic treatment was limited, and referral to tertiary centres was frequently delayed. In-hospital mortality among patients admitted with esophageal cancer was high, indicating extremely poor short-term survival in this setting.
Conclusions
Esophageal cancer represents a major contributor to cancer-related inpatient mortality at the district hospital level in rural Malawi. The findings highlight critical gaps along the cancer care continuum, from early detection to timely diagnosis and access to treatment. Strengthening referral networks, expanding decentralised diagnostic services, and integrating district-level mortality data into national cancer surveillance systems are essential steps toward improving esophageal cancer outcomes. This study underscores the value of routine hospital data in informing cancer control strategies in settings where population-based cancer registries are still evolving.