Clinicopathological Characteristics and Management of Esophageal Cancer in Mauritania: A Retrospective Study of 78 Cases at the National Oncology Center of Nouakchott

Background: Esophageal cancer remains a major public health concern worldwide, particularly in low-resource countries where late diagnosis and limited therapeutic options contribute to poor outcomes. In West Africa, epidemiological data are sparse, and no large-scale studies have been published in Mauritania.

Objectives: To describe the clinicopathological profiles, management strategies, and outcomes of esophageal cancer cases managed at the National Oncology Center (NOC) of Nouakchott and to provide foundational data for future cancer control strategies in Mauritania.

Methods: This retrospective observational study included all patients with histologically confirmed esophageal cancer who were treated at the NOC between January 2017 and December 2019. Sociodemographic, clinical, endoscopic, histopathological, therapeutic, and outcome data were extracted from archived medical records and analyzed using SPSS v20.0.

Results: Seventy-eight patients were included (mean age: 48.6 years, range: 18–81 years), with a male predominance (59%; male-to-female ratio, 1.4). Risk factors were undocumented in 73.1% of records; identified factors included Plummer-Vinson syndrome (14.1%), tobacco use (7.7%), and gastroesophageal reflux disease (GERD) (5.1%). Most cases originated from riverine regions (Trarza, Brakna, and Gorgol). Dysphagia was the most common symptom (91%). The lower third of the esophagus was the most frequent tumor site (38.5%). Squamous cell carcinoma accounted for 96.2% of the cases, and adenocarcinoma was rare (3.8%). Only 43.6% of cases had complete TNM staging, with most patients presenting at advanced stages (IV, 34.6%). Curative surgery was performed in only 2.6% of the patients, and most patients received palliative treatments. The overall mortality rate was 68%, with 16.6% of patients being lost to follow-up.

Conclusion: Esophageal cancer in Mauritania is characterized by the predominance of squamous cell carcinoma, early age of onset, advanced-stage diagnosis, and poor outcomes. Major challenges include diagnostic delays, lack of systematic screening, limited technical resources, and incomplete data. Establishing a national cancer registry, improving early diagnosis, and enhancing technical and human capacities are urgently required to improve patient outcomes.

Introduction

Esophageal cancer represents a major global public health challenge. In 2022, it was ranked as the 14th most common cancer worldwide by incidence, but the 8th leading cause of cancer-related mortality, reflecting a particularly poor prognosis, especially in low-resource countries [1].

In West Africa, the available data remain limited; however, several studies conducted in Mali, Senegal, and Morocco suggest a rising prevalence, particularly among younger patients [2].

In Mauritania, no large-scale study has been conducted to provide a detailed characterization of this disease.

Histologically, two main entities dominate: squamous cell carcinoma, which remains highly prevalent in low-income countries, and adenocarcinoma, which is steadily increasing in industrialized nations, particularly in obese patients with chronic gastroesophageal reflux disease (GERD) [3].

Squamous cell carcinoma is classically associated with well-established risk factors, including alcohol consumption, tobacco use, Plummer-Vinson syndrome, and repeated ingestion of very hot beverages [4], [5].

In the African context, several specific risk factors have also been identified, including consumption of certain foods, exposure to indoor charcoal smoke, and the presence of persistent viral infections [6], [7].

A major challenge remains the diagnostic delay: most patients present at an advanced symptomatic stage due to limited access to endoscopy, lack of screening programs, and low awareness of warning signs [8].

Nevertheless, upper gastrointestinal endoscopy combined with multiple biopsies and histopathological analysis remains the cornerstone of diagnosis and guides therapeutic decision-making [9].

In this context, the present study was conducted at the National Oncology Center (NOC) in Nouakchott, the only specialized oncology center in Mauritania, with the aim of addressing a local scientific gap.

We retrospectively analyzed 78 cases of esophageal cancer diagnosed between 2017 and 2019, using histo-clinical and longitudinal approaches, in order to better describe the epidemiological, clinical, endoscopic, histological, and outcome profiles.

Our objective is to provide a robust local dataset to support the development of strategies for early diagnosis, improved access to specialized care, and the structuring of management programs tailored to the realities of our healthcare system.

Materials and Methods

Study Design

This was a retrospective observational study conducted at the National Oncology Center (NOC) of Nouakchott. This study included 78 patients diagnosed with esophageal cancer. Cases were included over a three-year period, from January 1, 2017, to December 31, 2019.

Study Setting

The National Oncology Center (NOC) is a public institution specializing in cancer diagnosis, treatment, and research. It includes several specialized clinical and technical departments, namely:

• Medical oncology department (inpatient unit, day hospital, and outpatient consultations)

• Radiotherapy department, equipped with two linear accelerators (Clinac® and Halcyon®) and a planning CT scanner

• Nuclear medicine department, equipped with a gamma camera coupled with a CT scanner

• Radiology department (ultrasound, mammography, and conventional radiography)

• Anatomical and cytological pathology department (histology, cytology, and immunohistochemistry, particularly for breast tumors)

• Surgical operating theater

• Oncology pharmacy unit

• Dedicated pediatric oncology department operating independently.

Study Population

All patients with a histologically confirmed diagnosis of esophageal cancer during the study period were included.

Inclusion criteria:

• Histologically confirmed diagnosis of esophageal cancer.

Exclusion criteria:

• Incomplete or unusable medical records.

• Patients with esophageal lesions due to secondary metastases from another primary malignancy were excluded.

Data Collection

Data were extracted from archived medical records and validated manually. The following parameters were collected:

• Sociodemographic data: age and sex

• Medical history and time to consultation

• Clinical data at the time of diagnosis

• Lifestyle habits (tobacco use and alcohol consumption) when available in the medical records

• Results of endoscopic and radiological investigations (tumor location and extent of disease)

• Histopathological data (histological type, degree of differentiation, and invasion)

• TNM classification when documented

• Therapeutic modalities (surgery, chemotherapy, and radiotherapy)

• Patient outcomes, date of death, or vital status at the last follow-up

Statistical Analysis

Statistical analysis was performed using the SPSS software (version 20.0, IBM Corp., Armonk, NY, USA).

Qualitative variables were described as frequencies and percentages, whereas quantitative variables were expressed as means.

Methodological Limitations

This study had several limitations, including:

• The loss or incompleteness of certain medical records

• Missing data regarding medical history, risk factors, and lifestyle habits in a significant number of cases

• Limited access to follow-up data, particularly for patients lost to follow-up

• Heterogeneity in treatment modalities depend on the period of inclusion and resources available within the institution.

These limitations should be taken into account when interpreting the study results.

Results

A total of 78 cases of esophageal cancer meeting the inclusion criteria were collected at the National Oncology Center (NOC) in Nouakchott between January 2017 and December 2019. The mean age of the patients was 48.6 years (range, 18–81 years). The age distribution of patients is presented in Fig. 1.

Fig. 1. Age distribution of patients with esophageal cancer included in the study.

Male predominance was observed, with 46 men (59.0%) and 32 women (41.0%), yielding a male-to-female ratio of 1.4.

Risk factors were absent or not documented in 73.1% of medical records (n = 57). Among the remaining cases, the following risk factors were identified:

• Plummer-Vinson syndrome in 14.1% of cases (n = 11),

• Tobacco use in 7.7% of cases (n = 6),

• Gastroesophageal reflux disease (GERD) occured in 5.1% of cases (n = 4).

Geographically, the highest frequency of cases was observed in Trarza region, followed by Brakna and Gorgol.

Clinically, dysphagia was the primary presenting symptom, reported in 91% of the patients. It is either isolated or associated with weight loss or chest pain. The other presenting symptoms included epigastric pain (3.8%), vomiting (1.4%), and isolated chest pain (3.8%). General health status was impaired in 42% of patients at the time of initial consultation.

The mean interval between symptom onset and first medical consultation was 3 months (range, 1–8 months).

Endoscopically, the most frequent tumor location was the lower third of the esophagus (38.5%), followed by the middle third (37.2%) and upper third (21.8%). In 2.6% of cases, tumor location was not specified.

The most commonly observed endoscopic appearance was an ulcerative-exophytic type in 42.3% of cases. Stenosing forms accounted for 21.8%, while infiltrative or impassable forms were observed in 6.4% of the cases. An isolated exophytic appearance was rare (2.6%). In 20.5% of cases, endoscopic appearance was not documented in the medical report.

Histological analysis revealed a clear predominance of squamous cell carcinoma, found in 96.2% of cases (n = 75), with only three cases of adenocarcinoma (3.8%). A representative histological section is shown in Fig. 2.

Fig. 2. Representative histological section of well-differentiated esophageal squamous cell carcinoma (H&E stain, ×200).

Regarding tumor differentiation, an evaluation was performed in the 75 cases of squamous cell carcinoma. Among these, 53.3% were well-differentiated (n = 40), 37.3% moderately differentiated (n = 28), and 5.3% were poorly differentiated (n = 4). Tumor differentiation was not specified in 4.0% of the cases (n = 3).

A staging workup with a thoraco-abdominopelvic CT scan was available for 62 patients. Among these, 34.6% had no detectable metastases, 17.9% had locoregional involvement, and 20.5% had distant metastases.

TNM classification was determined in 43.6% of patients (n = 34).Across the entire cohort, 34.6% (n = 27) of patients were classified as stage IV, 6.4% (n = 5) as stage III, and 2.6% (n = 2) as stage II. No cases of stage I disease were identified. In 56.4% of the cases (n = 44), TNM staging was not documented.

Regarding treatment, surgery was primarily performed for palliative purposes, with gastrostomy or jejunostomy in 21.8% and 6.4% of the cases, respectively. Only two patients (2.6%) underwent curative esophagectomy. The majority of the patients (69.2%) did not undergo surgical treatment.

Chemotherapy was administered to 61.5% of the patients (n = 48), including 35.9% (n = 28) as part of a concomitant regimen and 25.6% (n = 20) with palliative intent. Chemotherapy was not performed in 38.5% of cases (n = 30).

Radiotherapy was administered to 46.2% of patients (n = 36), including 39.7% (n = 31) with curative intent and 6.4% (n = 5) with palliative intent. It was not performed in 53.8% of cases (n = 42).

Regarding the outcomes, data were available for all 78 patients. Clinical remission was observed in 30 patients (38.5%), while 17 patients (21.8%) experienced documented recurrence.A total of 53 patients (68%) died during follow-up, and 13 patients (16.6%) were lost to follow-up after initial treatment. However, these categories are not mutually exclusive.

An estimation of median overall survival could not be performed due to substantial loss to follow-up and missing data regarding the dates of death in several cases.

Discussion

In 2020, esophageal cancer was estimated to account for 604,100 new cases and 544,100 deaths worldwide, with an age-standardized incidence and mortality rates of 6.3 and 5.6 per 100,000 persons, respectively [10]. This incidence-to-mortality ratio reflects extremely high lethality, indicating that the disease is often diagnosed at an advanced stage. Several studies have reported that the five-year survival rate for esophageal cancer remains below 25% across all stages [11].

East Asian regions and the so-called "African Esophageal Cancer Corridor"—stretching from Ethiopia to South Africa—show the highest age-standardized incidence rates for esophageal cancer [12]. In contrast, West Africa, including Mauritania, remains among the regions with the lowest incidence, accounting for less than 1% of global cases according to WHO data. However, the mortality-to-incidence ratio of esophageal cancer in these settings remains disproportionately high, reflecting the impact of late-stage diagnoses and limited access to specialized care [10].

In Mauritania, a low-resource country in the Sahel region, epidemiological data on esophageal cancer remain scarce and fragmented. According to GLOBOCAN 2020 estimates, this cancer accounts for approximately 1.5% of all new cancer cases in the country, corresponding to about 49 new cases annually [1]. In our own series, 78 histologically confirmed cases were recorded at the National Oncology Center (CNO) of Nouakchott between 2017 and 2019, representing roughly 26 cases per year. This figure is numerically lower than the GLOBOCAN estimates, which likely reflects the fact that our data include only histologically confirmed cases managed at the national referral center. Many patients are diagnosed clinically without histological confirmation, treated outside the CNO, or remain undiagnosed due to limited access to diagnostic facilities, particularly in rural areas.

This observation is consistent with the conclusions of the most comprehensive retrospective epidemiological study published to date, based on 10 years of hospital-based data collection. The authors noted that ``the results do not reflect the incidence or the actual burden of cancer in Mauritania, as many diagnosed patients do not undergo histopathological examination." [13, p. 1].

In the absence of a national cancer registry, the true distribution of cancer types, their incidence, and mortality rates remain approximate.

The absence of a national cancer registry is not unique to Mauritania; it has also been reported in neighboring countries such as Senegal and Mali, where it represents a major obstacle to accurately assessing local epidemiology and significantly complicates the planning of public health strategies [14]. The present study addressed this gap by providing consolidated data on esophageal cancer in Mauritania based on a well-documented hospital-based series. These results offer a crucial foundation for improving national health planning for both early diagnosis and therapeutic decision making.

From this perspective, the implementation of a national cancer registry represents critical advancement. Such a tool would enable a more accurate estimation of disease burden, better monitoring of epidemiological trends, and more effective guidance of public health policies to fight cancer in the country.

In our cohort, the mean patient age was 48.6 years, ranging from 18–81 years. This finding is comparable to that reported in Senegal, where the mean age was 48 years [15].

This relatively early onset may be related to regional cofactors such as chronic anemia and infectious exposure [14]. Conversely, this mean age is lower than that reported in Morocco (60 years) [16] and in Mali (59.4 years) [17].

Male predominance of esophageal cancer was confirmed in our series, with 59% of patients being male (male-to-female ratio, 1.4). This trend is consistent with the global literature, which indicates that esophageal cancer affects men two to three times more frequently than women [10].

African studies also confirmed this marked male predominance, with sex ratios ranging from 1.7 to over 5 across various local cohorts [14], [16].

This male predominance is primarily attributed to the higher exposure to risk factors among men, particularly tobacco use and alcohol consumption, as well as certain occupational exposures.

The analysis of risk factors revealed a high proportion of medical records with missing information (73.1%), highlighting the challenges of collecting such data in routine clinical practice. Nevertheless, Plummer-Vinson syndrome, smoking, and gastroesophageal reflux disease (GERD) were reported in 14.1%, 7.7%, and 5.1% of cases, respectively, which are comparable to those reported in Moroccan and Senegalese studies [15], [16].

In Western countries, the rising incidence of esophageal adenocarcinoma is strongly associated with obesity and chronic gastroesophageal reflux, through the intermediate development of Barrett’s esophagus [3]. Conversely, in Africa, particularly in the Sahelian context, squamous cell carcinoma (SCC) remains predominant, with tobacco use and alcohol consumption representing the principal risk factors. In Togo, for instance, a study demonstrated that tobacco and alcohol consumption are in the majority of esophageal cancer cases [18]. In Morocco, 35% of patients in a hospital series were smokers, and 13% reported alcohol consumption [16].

These proportions remain lower than those observed in Western countries, reflecting the overall lower prevalence of alcohol consumption in North Africa. In Mauritania and Senegal, sociocultural and religious contexts further limit these behaviors. For example, Gaye et al. reported a very low prevalence of smoking and alcohol use among Senegalese patients [14].

In our cohort, no documented cases of alcohol consumption were recorded, while chronic smoking was reported in 7.7% of cases (n = 6). Additionally, the International Agency for Research on Cancer (IARC) has classified the consumption of beverages at temperatures ≥65°C as probably carcinogenic to humans (Group 2A) [19]. Moreover, studies conducted in Iran and Kenya, countries where the traditional consumption of very hot beverages is culturally widespread, have shown that the risk of esophageal squamous cell carcinoma is increased two- to fivefold among frequent consumers of very hot tea [5]. In Mauritania, the daily consumption of very hot green tea is a deeply ingrained cultural practice. This exposure could, therefore, represent a significant local risk factor in the etiology of esophageal cancer, although the retrospective nature of our study limited the ability to formally assess this factor.

In our study, an overrepresentation of cases originating from the riverine regions of Trarza, Brakna, and Gorgol was observed.This distribution may suggest the influence of specific environmental or socio-economic factors in these areas, although further studies are needed to establish a significant correlation.This observation is consistent with trends reported in African studies, which highlight geographic heterogeneity in the incidence of esophageal cancer across the continent, suggesting an important role of local environmental factors or dietary practices in the distribution of this disease [20].

Clinically, dysphagia was the main presenting symptom in 91% of cases in our series, consistent with the regional literature, which has been reported as the leading reason for consultation [14], [16].

The general health deterioration observed at diagnosis (42% of cases in our series) reflects a significant diagnostic delay, a phenomenon frequently reported in sub-Saharan Africa [15].

In our cohort, the mean interval between the onset of symptoms and the first consultation was three months, a delay longer than the median of 52 days reported by Baladi et al. in Morocco [21]. This prolonged delay may be explained by the subtlety of initial symptoms, the trivialization of early digestive signs, limited access to specialized care (due to geographical, socio-economic, and cultural barriers), as well as the frequent recourse to traditional medicine or self-medication [22]. These factors strongly contribute to the predominance of cancers diagnosed at advanced or metastatic stages and the difficulty in achieving complete TNM staging. In our cohort, TNM staging was determined in only 43.6% of cases (n = 34), with most patients already at an advanced stage: 34.6% (n = 27) at stage IV, 6.4% (n = 5) at stage III, 2.6% (n = 2) at stage II, and no cases were identified at stage I. For 56.4% of the patients (n = 44), TNM staging remained undetermined, reflecting both diagnostic delays and limited access to complete imaging workup.

This situation is consistent with observations reported in other African countries. In Senegal, most cases are diagnosed at an advanced stage, with a substantial proportion of records lacking complete TNM staging. This reflects the challenges in early diagnosis and adequate imaging [14].

In summary, the predominance of advanced stages, the complete absence of stage I cases, and the high frequency of records lacking TNM staging illustrate the extent of diagnostic delay in our setting. Improving access to endoscopy, imaging, and a structured diagnostic pathway remains a priority, in accordance with international recommendations [9].

Regarding endoscopic findings, the predominant tumor location in the lower third of the esophagus (38.5%) in our series was comparable to data from Morocco and Togo, where distal tumors also represented a significant proportion of cases [16], [18].

The ulcerative-exophytic appearance (42.3%) and stenosing aspect (21.8%) generally reflect advanced stages, as similarly reported in regional series [14], [16].

Histologically, the marked predominance of squamous cell carcinoma (96.2% of cases in our series) is consistent with data reported at the continental level, whereas adenocarcinoma remains very rare in Africa, unlike in Western countries, where its incidence is increasing [10].

From a therapeutic perspective, curative surgery was performed in only 2.6% of the patients in our series, while the majority received palliative treatments (gastrostomy, jejunostomy, palliative chemotherapy, or radiotherapy). This trend mirrors the situation observed in other Maghreb and West African countries, where access to surgery and curative therapies remains limited [15], [16]. The main limitations of curative surgery include patient frailty (malnutrition and comorbidities), locoregional tumor extension making resection impossible, and constraints related to technical facilities and available surgical resources. In practice, esophageal surgery remains uncommon in Mauritania due to its complexity (high morbidity) and the specific requirements for postoperative intensive care.

Concomitant chemoradiotherapy is a curative alternative for patients with locally advanced, non-operable forms of the disease. In our cohort, the availability of a linear accelerator at the National Oncology Center enabled some patients to receive radiotherapy, most often with palliative intent (pain relief or obstruction relief). However, concomitant chemotherapy was only used sporadically, primarily due to the poor general condition of many patients (low Karnofsky performance status) and resource constraints.

As a result, the majority of our patients received symptomatic palliative care. Overall, the therapeutic management of esophageal cancer in Mauritania is hindered by late diagnosis and limited technical resources. This situation, leading to numerous "lost therapeutic opportunities," has also been observed in many sub-Saharan African countries, where patients rarely benefit from optimal multimodal treatment. This underscores the urgent need to strengthen both diagnostic and therapeutic capacities in order to improve the prognosis of this disease.

The prognosis of esophageal cancer remains particularly poor, with very low five-year survival rates, especially in developing countries. In Western series, the overall five-year survival rate across all stages is estimated to be 15%–20% [23]. Although this figure has improved slightly with recent therapeutic advances, it remains among the lowest of all digestive tract cancers. In Africa, survival rates are even lower, primarily due to late diagnosis and limited therapeutic options [5].

In our cohort, the high mortality rate during follow-up (68%), along with a substantial proportion of patients lost to follow-up (16.6%), highlights the severity of this disease in our context and reflects the significant challenges encountered in both management and long-term follow-up. These findings are consistent with those reported in the Malian and Senegalese series [15], [17].

This study has several important limitations. First, it was conducted at a single center, the National Oncology Center in Nouakchott, which serves as the sole national reference institution for cancer care in Mauritania. This monocentric design may introduce a selection bias, potentially concentrating on the most severe cases and underestimating the true epidemiological burden in the general population, especially in rural areas. The retrospective nature of the data collection also led to information gaps, particularly regarding risk factors, dietary habits, and delays in care. Furthermore, post-treatment follow-up was limited, and a substantial proportion of patients were lost to follow-up. Finally, the absence of advanced diagnostic tools (such as endoscopic ultrasound or PET-CT) and molecular analyses has reduced the accuracy of staging and prognostic assessment.

Despite these limitations, this study makes a valuable contribution to our understanding of esophageal cancer in Mauritania. The results, when compared with the regional and international literature, reveal both similarities and local specificities, allowing for the formulation of recommendations adapted to the Mauritanian context.

Several areas of improvement emerged from these findings. The foremost among them is the need to establish a national cancer registry: a population-based registry would provide reliable epidemiological data on incidence, mortality, and survival, especially for esophageal cancer, to better guide public health policies. Strengthening the role of pathologists and promoting an early diagnosis should be prioritized. Pathologists play a central role, not only in histological confirmation, but also in prognostic assessment and therapeutic decision-making. Awareness campaigns focused on warning symptoms and risk factors (such as tobacco use and consumption of very hot beverages) should be developed, using health education programs tailored to local cultural realities.

From a therapeutic standpoint, upgrading technical resources is essential to improve multidisciplinary management.

In conclusion, esophageal cancer in Mauritania presents an epidemiological profile similar to that observed in the Sahel region: predominance among men, occurrence at a relatively young average age, predominantly late-stage diagnosis, and high morbidity and mortality. These findings highlight the challenges of early diagnosis and limited access to appropriate treatment in resource-constrained settings. The central role of the pathologist must be supported by a better-structured healthcare system and the establishment of a national registry. Prevention and screening should be promoted through campaigns targeting the main risk factors and the importance of early medical consultation in cases of dysphagia. All of these efforts, combined with the strengthening of diagnostic and treatment infrastructure, will be indispensable for improving the prognosis of esophageal cancer in Mauritania in the coming years.

Conclusion

Esophageal cancer in Mauritania displays an epidemiological and clinicopathological profile comparable to that seen elsewhere in the Sahel, with predominance among relatively young men, advanced-stage at diagnosis, and high morbidity and mortality rates. The dominance of squamous cell carcinoma and the rarity of adenocarcinoma reflect the local risk factors and sociocultural determinants. Diagnostic delays, limited access to endoscopy and imaging, and a lack of multidisciplinary management remain significant obstacles to optimal care. These findings highlight the urgent need to establish a national cancer registry, enhance the role of pathologists, and develop early detection and prevention programs tailored to the local context. Strengthening technical capacity, improving access to specialized care, and conducting targeted awareness campaigns are crucial for improving the prognosis of esophageal cancer in Mauritania.

Declarations

The present study was conducted in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of Interest

Conflict of Interest: The authors declare that they do not have any conflicts of interest.