Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries
Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries
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.
387-397
West, Malcolm
98b67e58-9875-4133-b236-8a10a0a12c04
30 January 2021
West, Malcolm
98b67e58-9875-4133-b236-8a10a0a12c04
West, Malcolm
,
GlobalSurg Collaborative
(2021)
Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries.
The Lancet, 397 (10272), .
(doi:10.1016/S0140-6736(21)00001-5).
Abstract
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.
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Lancet 2021 - Global Surg
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e-pub ahead of print date: 21 January 2021
Published date: 30 January 2021
Additional Information:
Funding Information:
This study was funded by the National Institute for Health Research Global Health Research Unit Grant (NIHR 17–0799) in a subset of contributing countries. We would like to pay tribute to Hosni Khairy Salem, a dedicated key member of the GlobalSurg Collaborative, who tragically lost his life in June, 2020.
Funding Information:
MIvBH reports personal fees from Mylan, Alesi Surgical, Johnson and Johnson, and Medtronic; grants and non-financial support from Stryker; and grants from Olympus, outside the submitted work. All fees were paid to MIvBH's employing institution. PB reports grants and personal fees from the Medical Research Council (MRC); grants from MRC, National Institute for Health Research Health Technology Assessment, and Wellcome Trust; and personal fees from AG Biotest, outside the submitted work. TPK reports personal fees from Olympus Surgical outside the submitted work. All other authors declare no competing interests.
Publisher Copyright:
© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license
Copyright:
Copyright 2021 Elsevier B.V., All rights reserved.
Identifiers
Local EPrints ID: 446807
URI: http://eprints.soton.ac.uk/id/eprint/446807
ISSN: 0140-6736
PURE UUID: b1fcbf6e-47fe-4312-be49-394022a343f7
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Date deposited: 23 Feb 2021 17:31
Last modified: 17 Mar 2024 03:46
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Corporate Author: GlobalSurg Collaborative
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