Patients’ chances of survival after cancer surgery is strongly linked with the standard of post-operation hospital care, with patients in low-and lower-middle-income countries were up to six times more likely to die from complications within 30 days of surgery compared with those in high-income countries, a 82-country study found.
Hospitals in these countries were found to be less likely to have post-surgical facilities or care plans in place. Investing in appropriate recovery and ward space, trained staff, early warning systems and critical care facilities would result in much improved surgical care and reduce the number of deaths, experts said.
In the largest study of its kind, published in The Lancet, researchers from the University of Edinburgh and the University of Birmingham examined data for nearly 16,000 patients in 428 hospitals across 82 countries who underwent surgery for breast, bowel and stomach cancer between April 2018 and January 2019.
Surgery is an important part of cancer treatment with 80% of cancer patients undergoing a procedure. Stomach cancer patients who underwent surgery were three times more likely to die in low and lower-middle income countries than those in high-income countries.
It was four times more likely for bowel cancer patients in low and lower-middle-income countries to die than those in high-income countries.
There was no difference in deaths between countries for patients who underwent breast cancer surgery.
Complications following surgery are common, but hospitals that provide a high standard of post-operative care had the best outcomes, even when treating late-stage cancers, the study found.
Low- and lower-middle-income-countries that had post-operative care facilities in place were associated with seven to ten fewer deaths per 100 complications.
The research has been funded through the National Institute for Health Research Global Health Research Unit in Global Surgery.
The team only looked at early outcomes following surgery, but, in future, they plan to study longer-term outcomes and other cancers.
“Rich and poor countries alike have talented surgeons and anaesthesiologists, but low resource countries do not have the infrastructure to support the complications that occur during surgery. We now know this can have a major impact on whether or not a patient survives,” said Ewen Harrison professor of surgery and data science, University of Edinburgh.
Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries
GlobalSurg Collaborative and National Institute for Health Research and Global Health Research Unit on Global Surgery
Published in The Lancet on 21 January 2021
80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.
This was a multicentre, international pro
prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.
Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.
Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening peri-operative care systems to detect and intervene in common complications.
National Institute for Health Research Global Health Research Unit
Edinburgh University material
The Lancet study (Open access)