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-middleincome
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.
Original languageEnglish
Pages (from-to)387-397
JournalThe Lancet
Volume397
Issue number10272
DOIs
Publication statusPublished - 21 Jan 2021

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