Presentation, treatment patterns, and outcomes in patients receiving care for esophageal cancer in Southern Malawi: Cohort study at queen elizabeth central hospital and malamulo adventist hospital

Background: Esophageal cancer (EC) is a leading cause of cancer mortality in Eastern and Southern Africa.Prospective multicenter data from Malawi are limited.This study evaluates clinical presentation, symptom-based dysphagia staging, treatment, and survival among EC patients at Queen Elizabeth Central Hospital (QECH) and Malamulo Adventist Hospital (MAH) in Southern Malawi. Methods:We conducted a prospective cohort study of 172 adults with endoscopically confirmed EC from July 2022 to July 2024, with 12 months of follow-up.Clinical dysphagia severity served as a surrogate for TNM stage.Survival was assessed using Kaplan-Meier and Cox proportional-hazards models.Results: Median age was 56 years, and 93.6% of tumors were squamous cell carcinoma.Median delay to endoscopy was 4.85 months.Only seven patients underwent esophagectomy (all at MAH) with 0% perioperative mortality; 51.2% received chemotherapy.Median overall survival was 8.52 months.In univariable analysis, alcohol, smoking, feeding-tube placement, and advanced symptom-based severity were associated with worse survival, while chemotherapy was associated with improved survival.Timedependent effects were seen for consumption of very hot drinks, higher ECOG score, and treatment at MAH, all associated with early excess mortality.In a multivariable time-interaction model, independent predictors of mortality were feeding-tube placement, higher BMI at later time points and consumption of hot drinks.. Conclusions:EC patients in Malawi present late with poor survival due to delayed diagnosis and limited curative options.Chemotherapy is associated with improved survival, feeding-tube dependence reflects disease severity, and esophagectomy was safe but rare.Early diagnosis and curative therapies are much needed.