Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Abstract

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.

Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

“…All publications arising from TALON will be attributed to the NIHR Global Health Research Unit on Global Surgery [6,45,46]. All contributors will be listed as collaborating authors in accordance with the National Research Collaborative recommendations [47].…”

New approaches and procedures for cancer treatment: Current perspectives

“… 1 – 3 There were only a few options of cancer treatment for patients for many decades which include surgery, radiation therapy, and chemotherapy as single treatments or in combination. 4 , 5 But recently, many pathways involved in cancer therapy progression and how they can be targeted has improved dramatically, with combinatorial strategies, involving multiple targeted therapies or “traditional” chemotherapeutics, such as the taxanes and platinum compounds, being found to have a synergistic effect. 6 New approaches, such as drugs, biological molecules, and immune-mediated therapies, are being used for treatment even if the excepted therapy level has not reached that resists the mortality rate and decreases the prolonged survival time for metastatic cancer.…”

Profiling Colorectal Cancer in the Landscape Personalized Testing—Advantages of Liquid Biopsy

“…Colorectal cancer (CRC) represents the second most common cause of cancer-related death globally [ 1 ], with annual incidence approaching two million cases worldwide [ 2 ] ( Figure 1 ). Moreover, CRC incidence is rising in low-income and middle-income countries [ 1 ].…”

“…Colorectal cancer (CRC) represents the second most common cause of cancer-related death globally [ 1 ], with annual incidence approaching two million cases worldwide [ 2 ] ( Figure 1 ). Moreover, CRC incidence is rising in low-income and middle-income countries [ 1 ]. The disease results from the accumulation of multiple genetic and epigenetic modifications that lead to the transformation of colonic epithelial cells into invasive and aggressive adenocarcinomas [ 3 , 4 ].…”