Western Kenya has been identified as an area with a common occurrence of ESCC. Of patients that are diagnosed at Tenwek Hospital, about 6% are ≤30 years of age 
. This high percentage has not been reported anywhere else in the world. From January 1996 – June 2009, 109 such young EC cases were identified in this case series from Tenwek Hospital.
Among the total 109 cases and the 60 cases with follow-up information, the M:F ratio was close to 1.5
1. This is similar to the gender distribution of cases found in all EC patients seen at Tenwek (1.6
and in other high-risk populations in developing areas, such as Linxian, China 
and Golestan Province in northwestern Iran, 
. This M:F ratio is much lower than those found in industrialized countries 
. By far the most common histologically confirmed tumor type among the young EC patients seen at Tenwek was ESCC (95%), which is also the most common tumor type in adult patients at Tenwek 
and in other known high risk areas 
. This large percentage of ESCC may even be an underestimate, because some of the small number of EAC cases identified at Tenwek Hospital may have originated in the gastric cardia.
Two primary risk factors for esophageal cancer in Western populations are smoking tobacco and drinking alcoholic beverages in excess 
. We found that tobacco and alcohol consumption were reported by only a minority of young EC cases at Tenwek, which supports the argument that although these exposures are associated with EC in developed countries, they do not seem to be major etiologic factors in this area. This finding is similar to other developing, high-risk ESCC areas in China 
and Iran 
. Notably, almost 80% of patients in this case series had a family history of cancer, including a 43% with a specific family history of EC, which is a higher percentage than in cases from a high risk area in China 
but lower than in cases from a high-risk area in Iran 
. The contribution of other risk factors will require formal etiologic studies, but may include consumption of very hot tea 
, limited diet 
, exposure to polycyclic aromatic hydrocarbons 
, or genetics.
It is also important to note that most young patients in this series were of Kalenjin ethnicity, although the meaning of this is difficult to assess in a case-series. A similar proportion of Kalenjins has been reported among EC patients from the traditional catchment area around Tenwek Hospital 
. The high proportion of cases with a family history of EC and the apparent restriction to a specific ethnic background both suggest that genetic factors could be important in the etiology of EC in this area, but these observations could also reflect shared environmental risk factors such as socioeconomic status, diet, use of similar traditional medicines 
or foods, or communicable diseases.
Of the followed patients, survival was poor, with a median of 6.4 months, which is shorter than the still poor survival of 9.2 months seen for all EC cases in the United States 
. In all populations, the majority of EC cases are diagnosed at an advanced stage, and it appears that this is especially true among young patients at Tenwek. Local knowledge of the high case fatality rate may further discourage cases from coming to the hospital until the cancer is very advanced.
Our literature review shows that little is known about EC in young people in any population. We found several case series of young patients from India, but only limited reports from other countries. Taken together, these reports suggest that the occurrence of EC in patients ≤30 years of age is rare throughout the world; even in the large case series presented by Paymaster et al 
young EC patients comprised only around 1% of their cases. These literature reports also suggest that the demographic and tumor characteristics of EC in young patients are similar to those of EC in older patients from the same populations: the M:F ratio in the reported young patients was close to one (1.8
1) in cases from developing countries and was greater (2.5
1) in cases from developed countries, and the proportion of ESCC tumors was high (14/18, 78%) in cases from developing countries and it was low (3/15, 20%) in cases from developed countries.
In summary, this case series describes the largest number of young EC patients reported to date, and it highlights the uniqueness of the EC experience in western Kenya. The causes of the overall high incidence and the particularly high incidence in young people remain unknown and will require detailed epidemiologic studies of the local population.