Survival and Quality of Life of Patients after Rectal Cancer Surgery in a Low-Income Country: A Study in Cameroon, Sub-Saharan African Region

Background: Survival of patients after rectal cancer surgery as well as their quality of life (QoL) has been little studied in Africa and never in our country in particular. Methods: We conducted a cross-sectional multicentre study in Yaoundé (Cameroon). We reviewed operating reports of the selected departments to identify patients operated from January 2010 to December 2019 for a rectal cancer. The outcome of patients enrolled had to be known until December 2020. Patients who were alive were contacted to evaluate their QoL using the EORTC QLQ C30 (European Organization for Research and Treatment of Cancer QoL questionnaire). Results: During the study period, rectal cancer was ranked 4 th within the digestive cancers. We included 68 patients; their mean age was 49.74 years and 41.18% were under 45. The sex ratio was 1.19 in favour of males. The tumour was mainly located in the lower rectum (45.6%). The main surgical procedure implemented was abdomino-perineal resection (42.6%). Forty-one of rectal cancer in our context. The 5-year survival after rectal cancer surgery is poor while the QoL of living patients is good.


Introduction
Rectal cancer is one of the most frequent human malignant neoplasms. It represents 29.3% of cancers of the large intestine [1]. Rectal cancers are usually considered as a part of colorectal cancers (CRC) in related epidemiological studies.
According to GLOBOCAN 2018, over 1.8 million new CRC cases and 881,000 related deaths were estimated to occur in 2018, accounting for about 1 in 10 cancer cases and deaths; overall, CRC ranked third in terms of incidence of cancers but second in terms of cancer related mortality [2].
CRC incidence rate is about 3-fold higher in developed versus developing countries; however, the survival rate is lower in limited settings [2] [3]. Possible explanations are: delayed diagnosis with predominance of advanced stages [4] [5] [6] [7] [8], insufficient hospitals' technical platform [5] [9] [10] and poverty with absence of a national health insurance policy [9]. Some authors thus highlighted the "medical fracture" between recommendations of learned societies and the management of rectal cancers in our (poor) setting [10]. Rectal cancer in our environment is also characterized by a high proportion of young patients [4] [5] [6] [8] [11] suggesting a possible involvement of genetic factors [12].
The treatment of rectal cancer is based on several therapeutic modalities among which surgery occupies a prominent place. However, its association with neoadjuvant or adjuvant treatments (chemotherapy and/or radiotherapy) improves survival [13]. In Black Africa, accessibility to chemotherapy and radiotherapy is low due to the high cost and scarcity of dedicated services [9] [10] [14] [15] [16]. In this context, surgery is therefore often the only therapeutic modality implemented [14] [17].
To the best of our knowledge, no study has been carried out on the outcome of patients after rectal cancer surgery in our country; in particular, patients' postoperative QoL has been little studied in black Africa and never in our country. Therefore, we undertook this study with the aim of determining the survival and QoL of patients who had surgery for rectal cancer in our environment.  structions. All of the scales measures range in score from 0 -100, and a high scale score represents a higher response level. Thus, a high score for the global health status represents a high QoL, a high score for a functional scale represents a healthy level of functioning and a high score for a symptom scale/independent item represents a high level of symptomatology/problems.

Clinical Epidemiology
There were 37 men (54.4%) with a sex ratio of 1. 19 Table 1.

Survival
Out of the 68 patients in our study, the 30-day mortality was of 4.41% (n = 3); one of these deaths was related to stercoral peritonitis due to anastomotic fistula after anterior resection of the rectum and the two others to pulmonary embolism.

QoL
The overall QoL of the 27 living patients was good with a mean of 62.346 ± 15.907. Social function was the most affected item in the functioning scales. Pain and fatigue were the most common symptoms with a score of 33.33 ± 35.417 and 33.333 ± 20.884, respectively. Rectal cancer had a significant negative impact on the finances of almost all patients with a median score of 97.531 ± 8.896. Table 5 presents the normalized score of patients according to EORTC-QLQ C30. QoL of patients who had abdominoperineal excision wasn't poor compared to those who had anterior rectal resection (p = 0.06).  Concerning functional outcome, Sexual complications were found in 11 patients (40.74%) with 7 cases of erectile dysfunction (25.92%) and 4 cases of vaginal dryness with dyspareunia (14.81%). Four patients (14.81%) presented urinary disorders with 3 cases of urinary incontinence (11.11%) and one case (3.7%) of enuresis.
The main limitation of this study is related to the retrospective patient's selection.

Discussion
We conducted this study with the aim of determining the survival of patients af-  [16]. In western reports, the mean age of patients affected by rectal cancer is around 65 years [28] [29], even if rectal cancer incidence rates increased by 2.3% to 3.2% per year in adults ranging in age from 20 to 54 years since past decades [22]. We agree with Cronje et al. [12] that a genetic component in the pathogenesis of rectal cancer can be advocated in young black patients. In fact, they demonstrate that, most young patients (<50 years) with rectal cancer were significantly black than white (p ≤ 0.001) and loss of mismatch repair protein was more evident in black than in whites. However, further studies are needed to prove this hypothesis.
The survival of patients after rectal cancer surgery in our study was poor, with a 5-year survival of 21.87%. This result is similar to those reported in others African studies with a 5-year survival rate ranging from 3% to 22% [16] [30] [31]. Delayed diagnosis, limited accessibility to perioperative radiotherapy/chemotherapy and limited technical platform are possible explanations of these bad results.
Indeed, as in other malignant tumors, the diagnosis of rectal cancer is made late in our context with a predominance of advanced stages; in our study, 63.23% of patients presented with locally advanced/metastatic forms (stage IIC to IV). The average time from onset of symptoms to diagnosis was 9 months in a similar setting [30].
The therapeutic paths of African subjects are often long and tortuous before they are received in a "western hospital" environment, recourse to marabouts and traditional healers being the first reflex. The identification of absence of schooling was statistically linked to an increased risk of death, thus finds an avenue of explanation. In the case of rectal cancer, tenesmus has been identified as a sign of a locally advanced stage [32], and is related to a bad prognosis in our study.
Poverty and the absence of a national health insurance system can also explain the diagnostic delay and the poor accessibility of our patients to perioperative chemotherapy/radiotherapy. In our context, patients must pay directly out of their pockets, all the costs relating to their care. It's therefore understandable that chemotherapy and/or radiotherapy protocols are beyond the reach of most of them. In this study, neoadjuvant and adjuvant treatments were administered to only 20.6% and 22.01% of patients respectively and only one of them received radiotherapy. Similar results are reported in African studies [9] [10] [14] [15] [16] [25]. In our country there exist only one radiotherapy department and it is not located in the capital of the country where our study took place. Our patients, with predominant advanced disease should benefit from down staging prior to surgery as recommended [13]. We identified postoperative chemotherapy (p = 0.015), surgical site infection (p = 0.003) and postoperative bowel obstruction (p = 0.015) as independently associated with a diminished survival. In high-income countries, with screening programs and an adequate technical platform, 5-year survival rates varying from 54.4% to 73% have been reported [33] [34] [35].
This study assessed prospectively the QoL of patients after rectal cancer sur-  [35]. To the best of our knowledge, this study is the first to assess the QoL of patients after rectal cancer surgery in our country. Due to the absence of a national insurance policy and the low-income context, it's not surprising that rectal cancer surgery had a negative financial impact on almost all of our patients. The instauration of a universal health coverage system in our country and in black Africa in general could be a solution.
The prevalence of sexual dysfunction was high in our series (40.74%). Sexual problems after rectal cancer surgery are common; females are more affected than males [23]. We think that sexual dysfunction could have a negative impact on patients' QoL, especially regarding their young age in our series. Unfortunately, sexual (and urinary) complications are not specifically mentioned as item in the EORTC QLQ C30. More attention should be drawn in this topic in further studies.
The main limitation of this study is related to the retrospective identification of operated patients. Thus, of the 105 patients identified as having been operated on for a rectal tumor, only 68 (64.7%) were collected. The lack of computerization of medical files in our context, associated with non-rigorous archiving of the (paper) files used, leads to a significant loss of data. Our sample is therefore relatively small.

Conclusion
There is a low hospital incidence of rectal cancer in our context; young adults under 50 years are more affected. The 5-year survival after rectal cancer surgery is poor. QoL of living patients is good despite a high prevalence of sexual dysfunction.

Authors' Contribution
GAB conceited the study. EPS and GBM collected the data, which were analyzed by JYF, YMEB and DBB. GAB and EPS wrote the paper. DBB, OO and AE revised and edited the work. MAS gave the final approval.