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.
Aims: Patients referred with red flag colorectal cancer symptoms are seen within 2 weeks of referral and require completion of treatment within 62 days of referral. The demand on resources is such that the remit of this rapid access pathway (RAP) is to diagnose or exclude cancer quickly. It is hypothesised that patients on these pathways are less likely to have their symptoms addressed and more likely to be dissatisfied with the service received. Study Design: Questionnaire based study of all patients attending new colorectal outpatient appointments, both routine and RAP. Place and Duration of Study: All patients referred the colorectal department at West Suffolk Hospital, a district general hospital, during January 2018 were sent a questionnaire 6 months later. Methodology: Results were analysed for statistically significant differences between the two groups in relation to patient satisfaction. Results: Of 273 new patients, questionnaires were returned by 78 patients attending rapid access clinics and 61 attending routine new appointments. There was no significant difference in the overall level of satisfaction with the overall investigation and management process between patients seen in rapid access clinics or routine new appointments (P = 0.867). Patients on the RAP were less likely to have been given a diagnosis (p = 0.001) or advice on managing their symptoms (P = 0.002). When assessing a number of variables, only patients whose symptoms had resolved were significantly more satisfied with the overall care pathway (P = 0.037). Conclusion: Patients seen on the RAP are not less satisfied with their care.
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