Background
Esophageal cancer (EC) remains a major global health challenge and is associated with poor prognosis, particularly in low- and middle-income countries. In sub-Saharan Africa (SSA), EC is among the leading causes of cancer-related mortality, with esophageal squamous cell carcinoma (ESCC) accounting for the vast majority of cases.The Harmonized Guidelines for SSA were introduced by the National Comprehensive Cancer Network (NCCN)  to adapt evidence-based recommendations to regional resource constraints. However, population-based data evaluating treatment patterns, guideline concordance- and survival outcomes in SSA are scarce.
Objectives
To characterize diagnostic practices, treatment approaches, adherence to NCCN Harmonized Guidelines, and survival outcomes among patients with esophageal cancer in SSA, as well as to assess the impact of treatment guideline concordance on overall survival.
Methods
We conducted a retrospective study from 15 population-based cancer registries across 13 SSA countries. Patients diagnosed with EC between 2017 and 2022 were randomly selected. Demographic, clinical, diagnostic, staging, treatment, and follow-up data were obtained from cancer registry databases, hospital medical records, and patient tracing. The study population was categorized into three analytical cohorts: an entire cohort (n=810), a traced therapy cohort with detailed treatment information for both esophageal adenocarcinoma (EAC) and ESCC (n=507), and a traced survival cohort of M0 ESCC patients with at least 30 days of follow-up (n=229). Disease stage was assigned using available TNM information and clinical data. Treatment concordance for M0 disease was assessed using a simplified stage-specific framework based on NCCN Harmonized Guidelines. Overall survival (OS) was estimated using Kaplan-Meier methods, and possible associations between treatment concordance and mortality were evaluated with a multivariable Cox proportional hazards regression.
Results
In the traced therapy cohort, the median age at diagnosis was 60 years, and 59.2% of patients were male. ESCC accounted for 87% of cases. Most Patients presented at locally advanced (57.5%) or metastatic disease (22.4%), while early-stage disease was rare. Among patients with M0 ESCC, only 52% received any active oncologic treatment. Guideline-concordant care was uncommon: 5.9% received concordant treatment, 15.9% had minor deviations, 31.9% had major deviations, and 26.7% received no cancer-directed therapy. Chemotherapy alone was the most frequently administered modality.
For ESCC, 1-, 2-, and 3-year OS were 60.4%, 33.7%, and 24.4%, respectively. Survival differed significantly according to treatment type and guideline concordance. Major deviations from guideline-recommended treatment were found to be associated with a more than two-fold increased risk of death (hazard ratio [HR] 2.36; 95% CI 1.09–5.14). The same was true for no cancer-directed therapy (HR 2.41; 95% CI 1.04–5.60). Minor deviations showed a trend towards increased mortality. Age, sex, ECOG performance status, and HDI were not found to be associated with survival after adjusting for guideline concordance.
Conclusions
This large population-based analysis demonstrates that survival from ESCC in SSA remains poor. Despite diagnostic confirmation in most patients, early detection and curative-intent therapy are uncommon. Strengthening early diagnostic pathways, expanding access to radiotherapy and surgery, and improving adherence to NCCN Harmonized Guidelines are essential to improving esophageal cancer outcomes in SSA.

survival according to treatment concordance in M0 ESCC with FU >30 days (n=229)