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Meta-Analysis
. 2023 Sep 14;23(1):1782.
doi: 10.1186/s12889-023-16629-0.

Environmental and life-style risk factors for esophageal squamous cell carcinoma in Africa: a systematic review and meta-analysis

Hannah Simba  1   2 , Helena Kuivaniemi  3 , Christian C Abnet  4 , Gerard Tromp  3   5   6 , Vikash Sewram  7
Affiliations
Meta-Analysis

Environmental and life-style risk factors for esophageal squamous cell carcinoma in Africa: a systematic review and meta-analysis

Hannah Simba et al. BMC Public Health. .

Abstract

Background: The African Esophageal Squamous Cell Carcinoma (ESCC) corridor, which spans from Ethiopia down to South Africa, is an esophageal cancer hotspot. Disproportionately high incidence and mortality rates of esophageal cancer have been reported from this region. The aim of this study was to systematically assess the evidence on environmental and life-style risk factors associated with ESCC in African populations.

Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and carried out a comprehensive search of all African published studies up to March 2023 using PubMed, Embase, Scopus, and African Index Medicus databases.

Results: We identified 45 studies with measures of association [odds ratio (OR), relative risk (RR), and 95% confidence intervals (95%CI)], which reported on several environmental and lifestyle risk factors for ESCC in Africa. We performed a meta-analysis on 38 studies investigating tobacco, alcohol use, combined tobacco and alcohol use, polycyclic aromatic hydrocarbon exposure, hot food and beverages consumption (which served as a proxy for esophageal injury through exposure to high temperature), and poor oral health. We found significant associations between all the risk factors and ESCC development. Analysis of fruit and vegetable consumption showed a protective effect. Using population attributable fraction (PAF) analysis, we calculated the proportion of ESCC attributable to tobacco (18%), alcohol use (12%), combined tobacco and alcohol use (18%), polycyclic aromatic hydrocarbon exposure (12%), hot food and beverages intake (16%), poor oral health (37%), and fruit and vegetable consumption (-12%).

Conclusions: Tobacco smoking and alcohol consumption were the most studied risk factors overall. Areas where there is an emerging body of evidence include hot food and beverages and oral health. Concurrently, new avenues of research are also emerging in PAH exposure, and diet as risk factors. Our results point to a multifactorial etiology of ESCC in African populations with further evidence on prevention potential.

Keywords: African esophageal cancer corridor; Attributable risk; Esophageal cancer; Risk factors; Systematic review.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Outline of the study using the PRISMA diagram
Fig. 2
Fig. 2
Effect of tobacco use on esophageal cancer in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. First all studies listed here in chronological order were included in the meta-analysis (Additional file 3). Then studies that were considered outliers were removed from the final meta-analysis by setting their weight to 0%. OR, odds ratio; CI, confidence interval
Fig. 3
Fig. 3
Effect of alcohol consumption on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. Additional file 4 shows the initial analyses before outliers (indicated here with weight of 0%) were removed. OR, odds ratio; CI, confidence interval
Fig. 4
Fig. 4
Effect of combined tobacco and alcohol use on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. Additional file 5 shows the initial analyses before outliers (indicated here with weight of 0%) were removed. OR, odds ratio; CI, confidence interval
Fig. 5
Fig. 5
Effect of hot food and beverages on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. Additional file 6 shows the initial analyses before outliers (indicated here with weight of 0%) were removed. OR, odds ratio; CI, confidence interval
Fig. 6
Fig. 6
Effect of PAH on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. Additional file 7 shows the initial analyses before outliers (indicated here with weight of 0%) were removed. OR, odds ratio; CI, confidence interval
Fig. 7
Fig. 7
Effect of oral health on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. OR, odds ratio; CI, confidence interval; DMFT, sum of the number of Decayed, Missing due to caries, and Filled Teeth in the permanent teeth; TFI, Thylstrup-Fejerskov index
Fig. 8
Fig. 8
Effect of fruits and vegetables consumption on ESCC in Africa. The forest plot was generated using the R software. Study column gives the first author and the year of the publication. Additional file 8 shows the initial analyses before outliers (indicated here with weight of 0%) were removed. OR, odds ratio; CI, confidence interval
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