Background <p>Gastroesophageal junction (GEJ) cancer has remained a significant global health challenge due to late-stage diagnosis and poor survival outcomes. This study presents the 10-year institutional experience in the multimodal management of non-metastatic GEJ cancer in a low-resource setting.</p> Methods <p>This is a retrospective cohort study of 101 patients with non-metastatic GEJ cancer. Data on demographics, tumor characteristics, management approach, and outcomes were analyzed. Outcomes of patients who underwent neoadjuvant therapy versus outright surgery were compared.</p> Results <p>Majority of the patients were males (76%), with a mean age of 56 years old (SD 11.6) and adenocarcinoma as the predominant histology (85%). Of the cohort, 40% underwent neoadjuvant therapy, predominantly FLOT chemotherapy regimen (37%) and CROSS chemoradiotherapy regimen (54%). Definitive surgery primarily left thoracoabdominal approach with distal esophagectomy and total gastrectomy, and Roux-en-y esophagojejunostomy was performed in 60% of the cases. Neoadjuvant therapy was associated with reduced margin positivity and improved tumor regression; however, it had a high rate of incomplete treatment due to toxicity or progression. Surgical and medical complications occurred in 18% and 26%, respectively, with a 7% in-hospital mortality rate. The overall survival was 14%, and the 2- and 5-year cancer-specific survival was higher in the neoadjuvant group compared to upfront surgery.</p> Conclusions <p>This study underscores the benefits of a multimodal treatment strategy in non-metastatic GEJ cancer; however, challenges, including low institutional surgical volumes and treatment-related toxicity, highlight areas for improvement. Strengthening multidisciplinary collaboration and access to advanced systemic therapies are essential to optimize patient outcomes in resource-limited settings.</p>