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The Lancet Oncology: Over three-quarters of people with cancer worldwide have no access to safe surgery

September 28, 2015

Over 80% of the 15 million people diagnosed with cancer worldwide in 2015 will need surgery, but less than a quarter will have access to proper, safe, affordable surgical care when they need it, according to a major new Commission examining the state of global cancer surgery, published in The Lancet Oncology, and being presented at the 2015 European Cancer Congress in Vienna, Austria.

The Commission reveals that access is worst in low-income countries where as many as 95% of people with cancer do not receive basic cancer surgery. Yet despite this worldwide shortfall in access to cancer surgery, surgical care is not seen as an essential component of global cancer control by the international community.

According to lead Commissioner, Professor Richard Sullivan, Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, King's College London, UK, "With many competing health priorities and substantial financial constraints in many low- and middle-income countries, surgical services for cancer are given low priority within national cancer plans and are allocated few resources. As a result, access to safe, affordable cancer surgical services is dismal. Our new estimates suggest that less than one in twenty (5%) patients in low-income countries and only roughly one in five (22%) patients in middle-income countries can access even the most basic cancer surgery". [1]

Poor access to basic cancer surgery and good quality cancer care is not just confined to the world's poorer countries. Survival data across Europe shows that many of the poorer EU member states are not delivering high quality cancer surgery to their populations.

Without urgent investment in surgical services for cancer care, global economic losses from cancers that could have been treated by surgery will reach a staggering US$12 trillion by 2030 [2], equivalent to 1-1.5% of economic output in high-income countries (HICs) and 0.5-1% in low- and middle-income countries (LMICs) every year. Furthermore, the lack of effective action to train more cancer surgeons and improving cancer surgical systems could cost the global economy more than US$ 6 trillion between now and 2030, says co-author Professor John Meara, Director of the Program in Global Surgery and Social Change at Harvard Medical School in the USA.

Surgery is the mainstay of cancer control and cure, with over 80% of all cancers requiring some type of surgery, in many cases multiple times. Almost 300 different surgical procedures are used for diagnosis, curative, or palliative treatment of cancers in people of all ages including one in five children diagnosed with cancer.

The demand for cancer surgery is growing as many of the worst affected countries face rising cancer rates. By 2030, of the almost 22 million new cancer patients, over 17 million will need operations, 10 million of them in LMICs. "The global community can no longer ignore this problem," [1] says co-author Professor CS Pramesh, Head of Thoracic Surgery at Tata Memorial Centre, Mumbai, India. "By 2030, 45 million operations a year will be needed worldwide. The situation is particularly dire in low-income countries in sub-Saharan Africa and Asia where the need for cancer surgery is projected to increase by around 60% between now and 2030." [1]

The Commission also reveals that a third of people with cancer in LMICs who have a surgical procedure will incur financial catastrophe--costs that drive them into poverty. Another quarter will stop treatment because they cannot afford it.

With a serious shortfall of cancer surgeons in over 82% of countries, radical action is needed to train general surgeons to deliver basic cancer surgery, produce more gynaecological and surgical oncologists, and create more high quality surgical training programmes, say the authors. Other solutions to improve access to surgery include: better regulated public systems; growing international partnerships between institutions and surgical societies, such as SSO [3] and ESSO [4]; and a firm commitment to universal health coverage.

Educating policymakers, patients, and the public about the key issues in delivering safe, affordable, timely surgical care is also essential, say the authors. "Policy makers at all levels still have little awareness of the central importance of surgery to cancer control. Even recent studies of capacity building for cancer systems in Africa barely acknowledged the importance of surgery, focusing mainly on chemotherapy instead,"[1] says co-author Professor Riccardo Audisio, President of the European Society for Surgical Oncology.

According to the Commission, funding for research in cancer surgery is dire and needs urgent investment. Despite its huge impact on patient outcomes - with over 50% of survival in breast cancer, for example, credited to high quality surgery - just 1.3% of the annual global cancer research and development budget goes towards surgery. This figure is similar in the UK, with only 2.1% of research spending on cancer allocated to surgery. New estimates produced for the Commission find that 93% of global research in cancer surgery is done by just 34 of 195 countries. LMICs only account for 15% of this output, yet these countries urgently need to conduct research that is relevant to their settings.

According to Professor Sullivan, "This Commission clearly outlines the enormous scale of the problem posed by the global shortfall in access to cancer surgery and current deficiencies in pathology and imaging. The evidence outlined by the Commission, contributed by some of the world's leading experts in the field, leaves no doubt of the dire situation we are facing. It is imperative that surgery is at the heart of global and national cancer plans. A powerful political commitment is needed in all countries to increase investment and training in publicly funded systems of cancer surgery."[1]

[1] Quotes direct from authors and cannot be found in text of Commission.

[2] Cumulative gross domestic product (GDP) losses as a result of labour supply and capital stock.

[3] Society of Surgical Oncology;

[4] European Society of Surgical Oncology;

The Lancet

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