Evidence
Alert

Extra emphasis on care after cancer surgery could increase survival worldwide

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.

You may be interested to read

This NIHR Alert is based on: GlobalSurg Collaborative and National Institute for Health Research 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 National Institute for Health Research 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.

Commentaries

Study author

Very diligent surgeons and surgical teams are caring for patients around the world. But complications are common, they are a natural part of having cancer surgery. It’s what happens in response that makes the difference.

In high income countries, complications are identified quickly and acted on accordingly. In low and medium income countries, complications are not being identified quickly and so patients are sadly more likely to die. The key thing is whether the system has the capacity to manage a complication after it’s happened.

In the short term, we need to focus on improving the medical care patients receive before and after surgery.  Medium to long term, we need to identify specific improvements that are needed. We have to encourage funders and governments to provide money and resources to not only improve care facilities, but to measure their impact on patient outcomes.

There has been a strong focus on diagnosis and early detection, which we know will improve survival and quality of life.. But patients undergoing surgery need the best quality care to get them back to the life they want to lead.

Stephen Knight, Research Fellow, Usher Institute, Edinburgh Medical School, Edinburgh University 

Royal College of Surgeons

Established by the NIHR, the GlobalSurg collaborative was established to address the critical inequalities that exist in surgical care throughout the world. The study looked at the short-term outcomes for three of the most common cancers that require surgery: breast, gastric and colorectal. Data were collected from both high, and low and middle income countries (LMICs), and 30-day mortality rates were compared.

Patients undergoing cancer surgery in LMICs were more likely to die from their complications. Whilst this may partly be explained by advanced disease at presentation, the study team have suggested that this observation may also be explained by a lack of consistent perioperative care.

Overall this excellent study clearly further demonstrates the global inequality in healthcare. There is a moral imperative to further share the advances in perioperative care developed in the UK with LMICs. Furthermore, the observation of greater mortality in units where consistent post-operative care was lacking provides compelling evidence for further investment in the NHS as we continue to recover from the COVID-19 pandemic.

Peter Hutchinson, Director of Clinical Research and Dale Vimalachandra, Surgical Speciality Lead in Colorectal Surgery, The Royal College of Surgeons of England (RCS)

Community engagement professional 

This research raises awareness of the need for improved care in low-resource settings. It also highlights differences in the general health of patients before they have surgery – which plays a role in survival rates afterwards. The topic is complex and needs to be followed up with more research to identify the key reasons for lower survival rates in low and middle income countries.

The paper therefore provides a solid assessment of the issue, but the outcomes need to be investigated in more detail with a specific angle (on one country at a time, or specific steps of the care pathway, for example) to identify and implement interventions. Patient care and wellbeing should be a major focus of any research into complications after surgery, alongside survival rates.

Karolin Kroese, International Alliance for Cancer Early Detection (ACED) Programme Manager, Cancer Research UK 

Lived experience

I left hospital after treatment for prostate cancer without knowing what follow up would be provided. I had to find out myself through the internet that a blood test for prostate-specific antigen (PSA) is used to check I’m still in the clear. I have had irregular blood tests for other health issues since then, and I am not sure if a PSA test has been requested by my GP. I’d like to see closer monitoring of patients once they have been discharged from hospital. Clinicians, hospital discharge nurses and healthcare professionals working in the community, including GPs need better understanding of complications.

For this research to have an impact, local and national healthcare policies may need to be prioritised. Changes to hospitals and community healthcare may need additional resources to address postoperative cancer mortality.” 

Nanik Pursani, Public contributor, London