Global variation in postoperative mortality and complications after cancer surgery (A multicentre, prospective cohort study of 82 countries)

Cancer prevalence and its associated mortality is increasing in low-income and middle-income countries (LMICs): 

1. Of the 15·2 million individuals diagnosed with cancer worldwide in 2015, 80% needed surgery. 

2. Despite this need, fewer than 25% of people worldwide have robust access to effective surgical care. 

3. In tumours amenable to resection, surgery offers the best chance of cure, particularly in early-stage disease; thus, expanding the availability of surgery is likely to yield large improvements in cancer survival in LMICs.4 

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). Comparative postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. 

According to 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 particular study is registered with ClinicalTrials.gov, NCT03471494. 

Between April 1, 2018, and Jan 31, 2019, 15 958 patients were enrolled 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. 

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. 

With the reported rise in cancer patients in India, its about time that the root cause be further investigated vis-a vis mixture toxicological impact on human health especially within the farming community in India.