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.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.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.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.National Institute for Health Research Global Health Research
Unit.
