This study aimed at evaluating the short-term outcomes of patients diagnosed with gastric cancer in terms of hospital mortality and survival rates. It represents the first study of such kind ever done in the country, and is among few available in the sub-Saharan Africa.
In addition to outcomes, the present study established baseline demographic data of patients diagnosed with gastric cancer and identified some of the factors associated with mortality.
The mean age of patients with gastric cancer in this study was 55.4 years and this corroborates the findings from other sub-Saharan countries where the mean age is usually between 50 and 55 years [7, 8, 12]. Our patients developed gastric cancer at a younger age compared to patients from developed countries where a mean age above 60 years is usually reported [14, 15, 16].
The patients in this study had a delayed presentation with a mean duration of symptoms of 15 months from the onset of the first symptom to the time of the diagnosis. The delay in consultation and diagnosis is explained by the asymptomatic nature of the disease at its early stages. Several patients (74%) presented with advanced gastric cancer (Stage III and IV) at the time of the diagnosis. Delayed presentation was reported in other sub-Saharan countries with 92.1% patients presenting with advanced gastric cancer . The fact that patients presented with advanced disease has negatively affected their management, limiting the treatment options to palliative surgery in 25.3% or to non-surgical palliative treatment, like intravenous fluid therapy, analgesics, nutrition and oxygen supplementation for 55% of patients. In our study, only 45% of total patients underwent surgery and among them, only 19.8% were operated for curative intent while the remaining 25.2% underwent palliative procedures. Palliative surgical procedures mainly consisted of gastrojejunostomy (with or without jejunojejunostomy) and feeding jejunostomy. Similar findings were reported in Togo where the surgical management was possible in 46% of patients with gastric cancer including 15% palliative surgeries . Though the proportion of patients who undergo palliative surgeries is still high in Rwanda, it has markedly decreased compared to the findings of previous study done in 2007 where 97.1% of operated patients underwent palliative procedures .
The in-hospital mortality rate in our study was 13.3% which is consistent with the mortality rate reported in other sub-Saharan countries varying between 13.8% and 18.1% [7, 8, 12].
Gastric cancer was associated with poor outcomes, with an overall median survival of 7 months which is almost half of the median survival of 13.6 months found in Nigeria  and 1.09 years found in china . The 1 year survival rate of 28% found in this study was low compared to 51% and 52% reported in China for males and females respectively .The median survival rate was better in patients who underwent surgery with a post-operative median survival rate of 10.4 months compared to 1.6 months survival rate in patients who did not get surgery. This was expected because patients who were not operated on were judged to be in poor clinical status either due to the disease itself or due to the presence of other poor prognostic factors like severe malnutrition, comorbidities, or advanced malignancy. Those patients were managed with non-operative palliative measures such as intravenous fluids, pain killers, oxygen therapy and nutrition support where applicable.
The present study identified that age group in the thirties, presence of a poorly differentiated tumor, and the surgical procedure with palliative intent were associated with poor prognosis.
With regard to the age, most of the existing literature agrees that it does not affect the outcomes [17, 18, 19, 20] or that advanced age negatively impacts outcomes in patients with gastric cancer [15, 16, 21, 22]. However, some studies reported high prevalence of aggressive forms of cancer such as poorly differentiated tumors, diffuse type and signet ring cell carcinoma and other poor prognostic factors such as upper location of the tumor advanced stage at presentation in the young population [14, 23, 24]. The fact that the younger patients had better survival rates compared to old patients despite the presence of these factors suggests that age is not an independent predictor of mortality in patients with gastric cancer.
A poor prognosis in patients younger than 35 years was reported in some countries [25, 26] and there is some evidence that gastric cancer could be associated with poor outcomes in extremes of age (in younger population and in elderly) because of high prevalence of poor prognostic factors in the former group and the presence of comorbidities and cellular senescence in the latter, suggesting that, as far as age is concerned, a better prognosis is expected in the middle aged population . There is no conventional age cutoff to define elderly patients but the age of 65, 70 or 75 are commonly considered in the literature [27, 28, 29, 30, 31]
We did not find any factor that could explain high mortality in patients aged between 30 and 39 since none of poor prognostic factors reported in the literature was most prevalent in this specific age group and a large study with multivariate analysis is required to establish the role of the age on the survival of patients with gastric cancer in Rwanda.
Regarding the grade of the tumor, this study found that poorly differentiated tumors were negative predictors of survival (p: 0.012) and this corroborates the existing evidence of gradual decrease of survival with respect to the differentiation status .
The association between palliative surgery and mortality was expected since palliative procedures were performed on patients with advanced disease.
The effect of neoadjuvant and adjuvant therapies on patients’ outcomes was not assessed in this study because of insufficient data on patients who underwent chemotherapy. There was no radiation therapy available in the country before and during the study period.