Post-surgery death rates higher among cancer patients in lower-income countries

January 25, 2021

Research by an international team of medical experts has found cancer patients could be up to four times more likely to die following cancer surgery in low to lower-middle income countries than in high-income countries. It also revealed lower-income countries are less likely to have post-operative care infrastructure and oncology services.

The global observational study, published in The Lancet, explored global variation in post-operative complications and deaths following surgery for three common cancers. It was conducted by researchers from the GlobalSurg Collaborative and NIHR Global Health Unit on Global Surgery - led by the University of Edinburgh, with analysis and support from the University of Southampton.

Between April 2018 and January 2019, researchers enrolled 15,958 patients from 428 hospitals in 82 countries undergoing surgery for breast, colorectal or gastric cancer. This included a mix of patients from high-income countries, upper middle-income countries and low/lower middle-income countries. 53 percent (8,406) of patients underwent surgery for breast cancer, 39 percent (6,215) for colorectal cancer, and 8 percent (1,337) for gastric cancer. The authors analysed how common death or major complications were within 30 days of surgery.

Deaths among gastric cancer patients were more than three times higher in low/lower middle-income countries (33 deaths among 326 patients, 3.72 odds of death) than high-income countries (27 deaths among 702 patients).

Patients with colorectal cancer in low/lower middle-income countries were also more than four times more likely to die (63 deaths among 905 patients, 4.59 odds of death), compared with those in high-income countries (94 deaths among 4,142 patients). Those in upper middle-income countries were two times as likely to die (47 deaths among 1,102 patients, 2.06 odds of death) as patients in high-income countries.

No difference in 30-day mortality was seen following breast cancer surgery.

Similar rates of complications following surgery were observed in patients across all income groups, however those in low/lower middle-income countries were six times more likely to die within 30 days of a major complication (96 deaths among 133 patients, 6.15 odds of death), compared with patients in high-income countries (121 deaths among 693 patients). Patients in upper middle-countries were almost four times as likely to die (58 deaths among 151 patients, 3.89 odds of death) as those in high-income countries.

Patients in upper middle-income and low/lower middle-income countries tended to present with more advanced disease compared with those in high-income countries, however researchers found that cancer stage alone explained little of the variation in mortality or post-operative complications.

Assessing hospital facilities and practices across the different income groups revealed that hospitals in upper middle-income and low/lower middle-income countries were less likely to have post-operative care infrastructure (such as designated post-operative recovery areas and consistently available critical care facilities) and cancer care pathways (such as oncology services).

Further analysis revealed that the absence of post-operative care infrastructure was associated with more deaths in low/lower middle-income countries (7 to 10 more deaths per 100 major complications) and upper middle-income countries (5 to 8 more deaths per 100 major complications).

Academic lead at the University of Southampton and member of GlobalSurg, Mr Malcolm West, commented: "It was a great privilege for me to contribute to this landmark study. Failure to rescue from death after post-operative complications is of global importance. As a colorectal surgeon, it is disconcerting to see that patients in LMIC present with more advanced cancers compared to high-income countries. Interestingly, advanced cancer rates alone did not fully explain the high death and complication rates we have seen.

"An urgent focus on improving global healthcare systems, especially in LMIC, to detect and intervene when complications occur would help save lives following cancer surgery."

Professor Ewen Harrison, of the University of Edinburgh, said: "Our study is the first to provide in-depth data globally on complications and deaths in patients within 30 days of cancer surgery. The association between having post-operative care and lower mortality rates following major complications indicates that improving care systems to detect and intervene when complications occur could help reduce deaths following cancer surgery."

The authors acknowledge some limitations to their study. Researchers only looked at early outcomes following surgery, but, in future, they will study longer-term outcomes and other cancers. Outcomes can be poorly captured and understood in settings with limited resources, which will have affected the team's findings on the effectiveness of surgery. Further detailed analysis is needed to provide more robust evidence regarding associations between patient outcomes and hospital facilities.
Notes to Editors

1) This paper is published in The Lancet (DOI: 10.1016/S0140-6736(21)00001-5) and can be viewed here:

2) Mr Malcolm West is a National Institute for Health Research (NIHR) funded Clinical Lecturer in Surgery at the University of Southampton and a Royal College of Surgeons England Senior Fellow in Advanced and Robotic colorectal cancer surgery at St. Mark's Hospital, London. He is also a member of the GlobalSurg collaborative:

3) The University of Southampton drives original thinking, turns knowledge into action and impact, and creates solutions to the world's challenges. We are among the top 100 institutions globally (QS World University Rankings 2021). Our academics are leaders in their fields, forging links with high-profile international businesses and organisations, and inspiring a 22,000-strong community of exceptional students, from over 135 countries worldwide. Through our high-quality education, the University helps students on a journey of discovery to realise their potential and join our global network of over 200,000 alumni.

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