Association for Academic Surgery (AAS)

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Global Surgical Oncology

Surgery plays an essential role in the care of cancer patients. Surgery can be diagnostic, curative, palliative, and even preventative and in fact for many cancers, surgery offers the only chance of cure or long-term survival. But surgery is not available to many who need it.

This article aims to briefly describe the burden of the problem, the challenges, and avenues for improving cancer surgery in low- and middle-income countries (LMICs).

The incidence of cancer has been on the rise in both high income as well as LMICs. The World Health Organization estimates from 2012 place the global incidence at 14 million patients per year with an expected increase to 21.6 million patients per year by 2030.  Much of this increased incidence is expected to be in LMICs that are transitioning to a higher burden of non-communicable diseases as populations age and healthcare improves. In 2015 there were an estimated 8.8 million deaths due to cancer worldwide of which 65% occurred in LMICs. By 2030 it is estimated that about 17.3 million people will need cancer surgery around the world and about 10 million of these will be in LMICs.

If we ask the question – are LMICs equipped to deal with roughly 10 million cancer surgeries a year? The answer is an outstanding NO!  In fact, estimates show that not even 5% of patients in low income areas have access to timely and effective cancer surgery.

These numbers are astonishing! While the suffering and misery from the resultant disability and death are unmeasurable the economic consequences have been studied. The global surgical cancer mortality losses are estimated to amount to 7 trillion USD per year with an additional $400 billion from morbidity of surgical cancers.

Global Surgical Oncology is about the provision of timely, affordable, and quality surgery to these millions of cancer patients per year.

Like many global health crisis situations, there is no one solution to the problem and personnel from several different professions need to come together to address the problem. There is a need for primary data collection, training and education, scaling up screening programs, improving surgical safety, implementation, public policy, funding, and innovation.

A primary issue is that of data. Basic cancer epidemiology is lacking in LMICs and several questions remain unanswered. How many people need what kind of cancer surgery? How many surgeons, anesthesiologists and facilities are there? What is needed where? Is the surgery being performed safe? Is it effective? The Lancet commission on oncology looked at cancer surgery research around the globe and found that of all the cancer surgery related research being done 93% is done by 35 countries and the contribution from LMICs is only 15%. Additionally, only 1.3% of the global cancer research budget supports cancer surgery.  Registry data- vital to the understanding of cancer epidemiology, is sparse in LMICs with less than 2% of the population of Africa and less than 10% of the of the populations in Asia, Central America, and South America covered by a cancer registry (compared to near 100% in most HICs). There are several success stories of cancer registries operating at low cost in LMICs and the Union for International Cancer Control (UICC) has several resources to help countries develop and sustain such registry data.

A second major avenue of improvement is that of education and training. There simply are not enough surgeons available to address the surgical needs of the populations. When we look at the number of people requiring cancer surgery we see that the need is highest in HICs, however when we look at resources such as surgeons we find that LICs have a 10 fold higher cancer patient to surgeon ratio than HICs. While organizations such as the Society of Surgical Oncology, the Global Forum of Surgical Oncologists, and the International Gynecologic Cancer Society (IGCS) are working towards the education and training of cancer surgeons in LMICs the task appears unsurmountable and creative solutions will have to be sought to address this gap.

A third major challenge with cancer care in LMICs is that of stage at presentation. Cancers in LMICs often present at late stages when treatment options are limited. The case fatality is highest in LICs for all cancer subtypes and estimated to even be as high as 75%. Three quarters of all cancer patients dying is too large a burden. If we are to have a chance at decreasing mortality and morbidity from cancer we must make efforts to downstage the tumor.  While cancer screening has provided supremely effective in HICs there are many challenges to scaling this in LMICs and most of it is related to finances and awareness. Local solutions are needed to devise the optimal screening strategies specific to each LMIC.

What about the surgeries that are being performed? Are we utilizing our resources to maximum benefit? Are these complex operations safe? Can we improve the timeliness of these and what about their short term and oncologic outcomes? Several avenues of improvement exist here. The GlobalSurg3 study which is in its final stages focuses on the ‘quality and outcomes after global cancer surgery’ and should provide important insights in to this issue.

Innovation is and will be a core element to the provision of timely, effective, and quality surgical care for cancer patients in LMICs. Novel methods, devices and strategies are needed in all aspects – collecting data, training healthcare providers, screening tools, diagnosis, treatment guidelines, and follow up strategies. Resource stratified treatment guidelines, telemedicine, and new technology including solar powered PCR machines, high resolution microendoscopy, and point of care testing devices have shown promise.

Lastly, but at the crux of it all is public policy. Only governments have the ability to seriously scale up any strategy and provide it to the masses. Every country should have a national cancer control program or strategy which includes research, surveillance, screening, provision of services, (including surgery, medicine, radiology, pathology, radiation, supportive care), education and training, and infrastructure development. With innumerable challenges facing governments in LMICs– surgery and especially cancer surgery has been a low priority. It is up to academic global surgeons to help collect the evidence and propose effective solutions to gain public attention towards this global health crisis.

While global surgical oncology includes many overlapping themes from the larger ‘global surgery’ efforts there are many avenues unique and vital to cancer patients. A multipronged approach enhancing data, training, screening, policy, funding, and innovation related to cancer care is key to improving global cancer surgery.

Global Cancer Surgery
  • By 2030: 10 million patients needing cancer surgery in LMICs
  • Not equipped to handle this – high mortality/morbidity burden
  • Economic consequences to the world in trillions of dollars
Improving Cancer Surgery in LMICs
  • Need more data – registries and cancer surgery research
  • Training and education
  • Downstaging the tumor
  • Surgical Outcomes – safe surgery, quality improvement
  • Public policy and funding
  • Innovation

Sources and Further Reading

Syed Nabeel Zafar

Syed Nabeel Zafar is a current fellow in Surgical Oncology at the MD Anderson Cancer Center and proudly serves on the Global Affairs committee of the AAS. Nabeel completed his medical education from the Aga Khan University in Karachi, Pakistan, an MPH from the Harvard T.H. Chan School of Public Health, a general surgery residency from Howard University and an MIS fellowship from the University of Maryland. He is actively involved in health services research projects and his interests lie in enhancing surgery, especially cancer surgery in resource poor settings.