Mortality is higher after cancer surgery in lower-income countries, even when adjusted for patient characteristics, demonstrating the need for improved postsurgical care around the world, according to research in The Lancet.

Out of all patients with cancer worldwide, 80% need surgery at some point. Cancer mortality is increasing in low- and middle-income countries, and the disease remains a leading cause of death and disability worldwide.

This multicenter, prospective cohort study looked at postoperative outcomes for 15,958 adults with cancer across 82 countries. The researchers evaluated differences in outcomes based on high-income, upper-middle-income, or lower-middle- and low- income countries. The study focused on 3 common cancers worldwide: breast, colon, and gastric.

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Patients in low- and lower-middle income countries tended to present with more advanced disease than patients in higher-income countries. They were also more likely to be younger. These patients also experienced more surgical complications and higher 30-day mortality, particularly for gastric cancer and colorectal cancer.

A larger proportion of patients in upper-middle-income, low-income, and lower-middle-income countries underwent surgery for later stage disease for all 3 cancer types.

Patients in low- or lower-middle-income countries had higher 30-day mortality than patients in high-income countries for gastric cancer (10.1% vs 3.8%, respectively) and colorectal cancer (7% vs 2.3%, respectively). 

The study authors found that 30-day postoperative mortality is 4 times higher in resource-limited countries. Surgery at later-stage diagnosis accounted for some, but not all, of the increased deaths. Major complication rates were similar for all groups across all countries. However, mortality was higher in countries that did not have a postoperative care infrastructure. Lower-middle-income or low-income groups had fewer deaths if a postoperative care infrastructure was present, such as designated recovery areas, critical care facilities, and working CT machines.

These results suggest that 30-day postoperative mortality in lower-income countries is influenced not only by later stage at presentation but also by access to postoperative care. Finding ways to improve postoperative care can help reduce the burden of cancer death and disability worldwide.

Disclosures: Some authors have declared affiliations with or received grant support from the pharmaceutical industry. Please refer to the original study for a full list of disclosures.


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. Published online January 21, 2021. doi:10.1016/S0140-6736(21)00001-5