Gastric cancer remains a major global public health concern. In 2020, it accounted for more than one million new cases worldwide and 769,000 deaths, corresponding to approximately one in every thirteen cancer-related deaths globally [1]. It ranks fifth in incidence and fourth in cancer-related mortality and occurs nearly twice as frequently in men as in women [1].

In Africa, gastric cancer ranked ninth among all cancers in 2020, with 32,402 new cases (2.9% of all new cancer diagnoses) and 27,945 deaths, representing 3.9% of cancer-related mortality on the continent [2]. These figures highlight a substantial disease burden in settings where access to early diagnosis and specialized oncologic care remains limited.

In Benin, particularly in Cotonou, a descriptive and analytical cross-sectional study conducted in 2020 across three referral hospitals identified gastric cancer as the third most frequent primary digestive malignancy [3]. Despite its significant incidence, gastric cancer in this context is often diagnosed at an advanced stage, which profoundly compromises therapeutic options and survival.

Prognosis in gastric cancer is strongly correlated with tumor stage at diagnosis [4]. Surgery remains the cornerstone of curative treatment and represents the only modality with curative intent when complete tumor resection with adequate lymphadenectomy can be achieved, especially in early-stage disease [5]. However, in low-resource settings, delayed presentation, limited staging facilities, and restricted access to perioperative chemotherapy substantially reduce the proportion of patients eligible for curative surgery.

In Benin, several studies have addressed gastric cancer; however, only one, conducted approximately three decades ago, partially explored its surgical management [6][7]. Contemporary data focusing on access to surgical oncology care, operative practices, and postoperative outcomes are therefore lacking. The present study aims to evaluate the role of surgery in the management of gastric cancer in Cotonou, with particular emphasis on access to surgical treatment and patient prognosis.

In the present study, gastric cancer accounted for 11.8% of all surgical admissions in the participating hospitals. This proportion is consistent with findings from Cotonou, where Kpossou et al. reported that gastric cancer represented 12% of primary digestive cancers in 2020 [3]. Similar proportions have been reported in other African settings, including Togo, where Bouglouga et al. found gastric cancer to account for 12.8% of digestive malignancies [8]. In Mali, Diarra et al. reported a much higher proportion, with gastric cancer representing 59.1% of digestive cancers [9], highlighting marked regional variability across the continent. In Nigeria, Mandong et al. reported a lower proportion (3.6%) among malignant tumors [10].

The substantial burden of gastric cancer in Africa may be partly explained by inadequate identification and follow-up of high-risk populations. Early detection and endoscopic surveillance of at-risk individuals are well-recognized strategies to reduce gastric cancer incidence and mortality [7]. However, in many African countries, including Benin, organized screening programs are not publicly funded and remain largely dependent on patients’ financial capacity, which substantially limits access.

In high-income countries, a different epidemiological trend has been observed. Santos reported an incidence of 15.8 per 100,000 inhabitants in Peru [11], while Kamiya et al. described a steady decline in gastric cancer incidence in Europe, largely attributable to early detection and improved treatment strategies [12]. Similar findings were reported in the United States by Crew and Neugut, who observed a marked decrease in gastric cancer incidence over several decades [13]. Improved control of risk factors, systematic endoscopic surveillance, and timely treatment likely account for these favorable trends in developed settings.

The mean age of patients in our study was 57.2 ± 12.3 years, which is comparable to findings reported in Benin by Kpossou et al. (54 ± 14.1 years) [3] and in other African series, including Nigeria (51 ± 6 years) [13] and Kenya (median age 52 years) [14]. In contrast, studies from high-income countries report older patient populations, with a median age of 70 years in Poland [5] and a mean age of 62.9 years in Peru [11]. These differences suggest that gastric cancer tends to occur at a younger age in African populations, possibly reflecting demographic structure, environmental exposures, and disparities in access to preventive care.

Male predominance was observed in our cohort (61.5%), consistent with reports from Mali [9], Nigeria [15], and the United States [16]. Although exceptions have been reported, such as a female predominance in Rwanda [17], gastric cancer generally affects men more frequently than women across both African and non-African populations.

Upper gastrointestinal endoscopy was performed in 92.3% of patients, a rate comparable to that reported by Gbessi et al. in Cotonou (93%) [18] and higher than that reported in Tanzania (85.3%) [19]. In contrast, early endoscopic detection is significantly more effective in East Asia, particularly in Japan, where population-based screening and advanced endoscopic techniques, such as chromoendoscopy and magnification endoscopy, are widely available [13]. The widespread adoption of endoscopic screening in high-income countries has contributed substantially to earlier diagnosis and improved surgical outcomes.

Endoscopic biopsy remains the gold standard for preoperative histological confirmation of gastric cancer, allowing accurate pathological diagnosis and guiding therapeutic decision-making [18][20]. In our study, adenocarcinoma was the predominant histological type, consistent with previous reports [19][21]. However, access to advanced pathological testing remains limited. HER2 testing, which is recommended in metastatic gastric cancer to guide targeted therapy [22], was performed in only 1.9% of cases, reflecting the limited availability of immunohistochemistry in our setting.

Thoracoabdominopelvic computed tomography is the recommended imaging modality for staging gastric cancer [22], yet only 55.8% of patients in our study underwent CT scanning. Although access to CT imaging has improved over time in Benin, cost constraints and limited health insurance coverage continue to restrict its use. Abdominal ultrasound is sometimes used as an alternative to detect liver metastases, but it lacks sensitivity and is no longer considered sufficient for comprehensive staging [22].

Tumors were predominantly located in the distal stomach, particularly in the antropyloric region. This distribution is consistent with reports from Tanzania [19], Togo [8], and Senegal [21]. From a surgical perspective, distal tumor location theoretically allows for partial gastrectomy with curative intent when diagnosed at an early stage.

However, most patients in our study were diagnosed at an advanced stage, with stage III disease predominating. Similar findings have been reported in Tanzania [19] and Rwanda [17], where the majority of patients present with stage III or IV disease. In contrast, in Japan, the proportion of early-stage gastric cancer has increased markedly due to systematic screening, resulting in improved resectability and survival [4]. Tumor stage at diagnosis remains the key determinant of surgical strategy: early-stage tumors are more likely to be amenable to curative resection, whereas advanced tumors often require palliative surgical procedures.

Neoadjuvant chemotherapy is an integral component of multimodal treatment for gastric cancer, aiming to downstage tumors, increase R0 resection rates, and improve survival [23]. International guidelines recommend perioperative chemotherapy, typically administered as four cycles before and after surgery [15][22]. In our setting, access to chemotherapy remains inconsistent, reflecting regional disparities in oncology infrastructure and resource availability [19][24].

Partial gastrectomy was the most frequently performed surgical procedure in our cohort, consistent with the predominance of distal tumors and advanced-stage disease. Other African studies have reported higher rates of palliative procedures, including gastrojejunostomy, reflecting late presentation and low resectability rates [17][19]. Surgical decision-making in gastric cancer is fundamentally stage-dependent and must adhere to oncologic principles. Curative gastrectomy requires adequate proximal and distal margins (approximately 6 cm for antral tumors and 12 cm for cardial tumors) and is classified according to residual disease status (R0, R1, or R2). Adequate lymphadenectomy is a critical component of oncologic surgery, with D2 dissection currently recommended as the standard of care, while D1 is considered insufficient and D3 remains controversial outside specialized centers.

In our study, surgical management was compliant with international oncologic recommendations in 65.4% of cases. Non-compliance was mainly related to discrepancies between recommended surgical procedures based on tumor location and those actually performed, often reflecting late-stage presentation and limited intraoperative options.

The high proportion of patients who did not undergo surgical treatment likely reflects multiple interacting factors. Based on our clinical experience, these factors include financial barriers limiting access to diagnostic work-up and surgery, sociocultural constraints particularly fear and misconceptions surrounding surgical interventions as well as tumor-related factors such as poor operability and low resectability due to advanced-stage disease at presentation. However, given the retrospective nature of the study and the absence of standardized documentation regarding reasons for non-operative management, these factors could not be formally quantified and should be interpreted as contextual clinical insights rather than empirically measured determinants.

Median overall survival among the 18 patients included in survival analysis was six months, which is lower than that reported in other African series, such as Nigeria (13.6 months) [15] and Rwanda (10.4 months) [17]. In Western countries, five-year survival rates range between 10% and 15% [11]. These differences may be partly explained by the small sample size in our survival analysis, but also reflect advanced-stage disease at diagnosis and limited access to comprehensive multimodal care.

A major limitation of this study is the high loss to follow-up, which resulted in overall survival being assessed in only 18 of the 52 operated patients. This may have introduced selection bias, as patients with available follow-up data may not be representative of the entire operated population. For instance, some patients may have been lost to follow-up because they died at home without notification to the treating hospitals. Consequently, survival estimates should be interpreted with caution and considered exploratory. This limitation reflects the challenges of long-term patient follow-up in routine clinical practice in low-resource settings such as Benin, including incomplete contact information, financial constraints, and the absence of structured follow-up systems.

In addition, the high proportion of patients with undocumented nodal status (Nx) and the limited use of preoperative computed tomography imaging may have affected the accuracy of surgical compliance assessment and could have led to an overestimation of adherence to international surgical oncology recommendations.

Gastric cancer is not uncommon in southern Benin and continues to represent a significant surgical oncology burden. Although therapeutic strategies have evolved over time, resectability rates remain low, largely due to advanced-stage presentation at diagnosis. Surgery remains the cornerstone of curative treatment for gastric cancer and must be integrated within a multimodal approach that includes perioperative chemotherapy. Improving early diagnosis, timely staging, and access to standardized surgical oncology care is essential to increase curative resection rates and ultimately improve survival outcomes in this population.

We express our sincere gratitude to the staff of LEMACEN for their valuable contributions to this study.

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

During the preparation of this article, the generative artificial intelligence tool ChatGPT (GPT-5, OpenAI; accessed November 2025) was used occasionally to assist with translation and the reformulation of specific paragraphs. Its use was limited to linguistic clarifications, and all content was reviewed, validated, and finalized by the authors.

GFHR conceived the study. GFHR, LI, and AA designed the research and analyzed the data. AA collected the data. AA and GFHR performed the statistical analyses. GFHR, HR, and ASGR drafted the manuscript. LI, GR, and ASGR contributed to data interpretation and manuscript revision. All authors reviewed and approved the final manuscript.