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Complications can occur after cancer surgery, wherever in the world it is carried out. New research suggests that the care provided after surgery can determine whether patients survive.

It is often assumed that in low income countries, people are less likely to survive cancer because the disease is more advanced when diagnosed or because specific treatments are not available. These are important factors, but the new study suggests that poorer care after surgery may also be responsible for many deaths.   

Almost 16,000 patients from 82 countries were included in the study. It found that the chances of complications after surgery were similar, whether surgery took place in high, medium or low income settings. However, 30 days after surgery, patients in low income settings were much less likely to survive. 

The hospitals with the best survival rates after surgery had good facilities for people recovering from surgery. These included more intense observation, scanning, treatment and nursing care, than is provided on a general ward. 

Hospitals must have the capacity to treat patients who have complications after surgery, the researchers say. This will improve the safety and effectiveness of cancer surgery worldwide. 

Further information on what to expect after surgery is available on the NHS website.

What’s the issue?

The number of people with cancer is rising, with 15.2 million people diagnosed with cancer worldwide in 2015. Most (80%) will need surgery and there is little reliable, in-depth data about the effectiveness of cancer surgery and care in all countries.

This multi-country study was set up to improve our understanding of what is happening around the world, and to start to identify the areas that need improvement. The study focuses on the three most common causes of cancer-related deaths in low and middle income countries: colorectal (gut), breast and gastric (stomach) cancer. 

What’s new?

The study included data on 15,958 adults in 82 countries (in Africa, Asia, Europe, North and South America, and Oceania). Any surgical team that wished to take part could register their results using freely available software. In 2018 and 2019, teams enrolled everyone they had treated within a specified month. Patients were undergoing their first surgery for colorectal, breast, or gastric cancer. 

The results give a picture of cancer surgery outcomes around the world. The figures were adjusted to take account of patient factors (such as frailty or how advanced the cancer was) and hospital factors (such as what facilities were available). 

The study found that, 30 days after surgery:

  • for colorectal cancer, death rates were higher for patients from lower-middle or low income countries (7%), compared to high income countries (2%)
  • similarly, for gastric cancer, death rates were higher for patients from lower-middle or low income countries (10%), compared to high income countries (4%)
  • however, for breast cancer, death rates were similar across different income countries.

As expected, people having cancer surgery in low or middle income countries had more advanced cancer. But this did not fully account for the difference in death rates. Rates of complications were similar across high, middle and low income countries and therefore also did not explain the difference in death rates.

However, there were more deaths after a major complication in low and middle income countries. This suggests people in these countries were less likely to receive successful treatment for a complication. 

The researchers looked at which facilities and services were linked to death after complications. They found people were less likely to die if a hospital had:

  • designated post-operative recovery areas
  • critical care facilities that were always available
  • available, working computerised tomography (CT) scanner which uses X-rays and a computer to create detailed images of the inside of the body.

Researchers calculated that the presence of these facilities could account for:

  • 7 to 10 fewer deaths for every 100 complications in low or lower middle income countries
  • 5 to 8 fewer deaths for every 100 major complications in higher middle income countries.

Why is this important?

Many public health initiatives have focused on screening for cancer. Detecting cancer at an earlier stage when it is more successfully treated, does improve the chances of survival. This research suggests that efforts to improve care after surgery could also improve survival rates. 

The study is the first to identify the facilities that are linked to improved survival in hospitals in lower-income countries. It will allow hospitals and surgical teams in different parts of the world to identify factors that might account for higher death rates. This could be a prompt for resources to be directed to these areas of care.

What’s next?

The data from this study is being analysed in more depth to help answer further questions about how to improve the safety and effectiveness of cancer surgery. Researchers are looking at a longer time frame than the 30 days after surgery reported here. And they will study people who were treated in other ways, with medicines or radiotherapy, rather than surgery. 

The study does not prove that particular factors (such as CT scanners) reduce death rates. It simply shows that hospitals with CT scanners are linked to lower death rates after surgery. Future research should explore whether introducing new facilities or services actually makes a difference.

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This NIHR Alert is based on: GlobalSurg Collaborative and NIHR Global Health Research Unit on Global Surgery. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet 2021;397:387–97 

GlobalSurg Collaborative webinar discussing the results of this study: GlobalSurg 3 results webinar.  

GlobalSurg & The NIHR Global Health Research Unit on Global Surgery: a website providing information on the Global Surgery Collaborative and its work on improving surgical outcomes through collaborative research.  

Funding: This research was funded by the NIHR Global Health Research Unit. 

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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