Summary
Background
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.
Methods
This was a multicentre, international 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
.
Findings
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.
Interpretation
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 perioperative care systems to detect and intervene in common complications.
Funding
National Institute for Health Research Global Health Research Unit.
Objectives
To assess the impact of the eighth edition AJCC/TMN staging system on patients with new diagnoses of differentiated thyroid cancers presenting to our regional multidisciplinary team meetings.
Design
We analysed Endocrine Cancer MDT meeting records from 2009 to 2015 to identify all patients in the region presenting with a new diagnosis of differentiated thyroid cancer. We re‐staged patients according to the eighth edition AJCC/TNM staging classification and analysed the survival outcomes of patients in each stage under the seventh and eighth systems.
Setting
Tertiary referral centre in South East Scotland (NHS Lothian).
Participants
Three hundred and sixty‐one patients were newly diagnosed with DTC within South East Scotland during the study period and met our inclusion criteria. Main outcome measures: Disease‐specific mortality at any time during follow‐up.
Results
In total, 119 of 361 (33%) patients were re‐staged when the eighth edition AJCC/TMN system was applied. The number of patients classified as having advanced stage (III/IV) disease fell from 76 (21%) to 8 (2%). The most common reason for down‐staging was re‐classification of tumour size, a factor in 96 (80.7%) down‐staged patients. The five‐year disease‐specific survival of the cohort overall was 98%. Overall, 7 (1.9%) thyroid cancer–related deaths occurred during follow‐up, three of whom were down‐staged.
Conclusions
On implementation of the eighth edition of the AJCC/TMN staging system, we expect many patients who would previously have been considered to have advanced thyroid cancer will now be classified as early stage. This will accurately reflect their excellent survival outcomes.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.