Elsevier

The Lancet Oncology

Volume 16, Issue 11, September 2015, Pages 1193-1224
The Lancet Oncology

The Lancet Oncology Commission
Global cancer surgery: delivering safe, affordable, and timely cancer surgery

https://doi.org/10.1016/S1470-2045(15)00223-5Get rights and content

Summary

Surgery is essential for global cancer care in all resource settings. Of the 15·2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US$6·2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery—eg, pathology and imaging—are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Introduction

Surgery is essential for cancer treatment, and has a long and distinguished history.1 This Lancet Oncology Commission on global cancer surgery builds on the foundations laid by the Lancet Commission on global surgery and its report, Global Surgery 2030.2 Global Surgery 2030 detailed the need to build global surgical systems focusing on the most underserved populations; however, it recognised that many key disease areas, such as cancer, with major surgical burden, needed a more in-depth analysis to provide specific recommendations. This Commission fills this gap, drawing on a global faculty with extensive experience in all income settings and professional domains (eg, education, research, and economics).

Global Surgery 20302 showed that surgery interfaces with every primary care disease, from cataracts to pregnancy complications, congenital anomalies, infectious disease, heart disease, and malignancies. In 2010, an estimated 16·9 million lives (32·9% of all deaths worldwide) were lost from disorders that needed surgical care. Additionally, investment in surgery and anaesthesia is affordable and moreover promotes economic development. Without investment in surgical care there will be an estimated cumulative loss to the global economy of US$20·7 trillion, or 1·3% of the global projected economic output by 2030; most of these losses will occur in low-income and middle-income countries (LMICs). With so many cancers being amenable to surgical intervention, the importance of focusing on this area was clear.

Surgery is one of the major pillars of cancer care and control; it can be preventive, diagnostic, curative, supportive, palliative, and reconstructive. In the context of cancer, preventive surgery is performed to remove tissue that is likely to become cancer; for example, colposcopy for atypical cervical lesions. Diagnosis through procedures such as biopsy is essential for correct management of the cancer. Treatment of cancers that present early, such as breast and colon, and a few that present in an advanced state—eg, testicular cancer—always need surgery to be cured. Surgical resection is also crucial for palliative care, such as mastectomy for advanced breast cancers to improve quality of life, palliative stomas for malignant bowel disease, and stenting to relieve a range of malignant obstructions, and reconstructive surgery is used to improve cosmesis after mastectomy and for various head and neck operations.

One of the key challenges of this Commission has been to represent accurately the universals of global cancer surgery and also the differences; differences driven by history, geography, disease burden, economics, and other factors. Cancer surgery encompasses a wide range of surgical procedures at different levels of complexity that need different levels of infrastructure. Although cancer surgery has become increasingly subspecialised in high-income countries (HICs), in many LMICs surgeons are often the only health-care professionals treating cancer by delivering chemotherapy and performing endoscopies and even radiological examinations. To address such a broad spectrum, we have taken a practical systems approach to cancer surgery. This approach shows the reality of cancer care, education, and research; these domains are indivisible from one another. Cancer surgery is also part of a system that requires all its crucial parts—eg, pathology, radiotherapy, and imaging—to achieve the best outcomes for patients. Throughout this Commission, when talking about cancer surgery we also mean anaesthesia, as well as the vital role of both imaging and pathology. Although we will continually refer to cancer surgery, we also take this term to encompass the essential preoperative and postoperative care, and the central role of anaesthesia. These parts of the surgical system have been fully explored in Global Surgery 2030.2

Surgery is a fundamental method for both curative and palliative treatment of most cancers in countries across all income settings. However, with many competing health priorities and substantial financial constraints in most low-income countries (LICs) and many middle-income countries (MICs), surgical services are given low priority within national cancer plans and are allocated few resources from domestic accounts or international donor assistance programmes. As a result, access to safe, affordable surgical services for cancer is poor, with large proportions of the population unable to access even the most basic surgical care. Locally advanced or metastatic cancer is a common initial disease presentation and surgical resection may be the only available method to achieve reasonable palliative control. In HICs, where the most common solid organ malignant cancers (eg, breast and colon) are more likely to be successfully diagnosed at early stages, surgical resection provides definitive locoregional control of the primary tumour, which has substantial curative potential when combined with appropriately selected adjuvant systemic treatment and radiotherapy.

We have drawn on existing published evidence, findings from Global Surgery 2030,2 various commissioner meetings, and original analyses to assess the state of global surgery across all income settings with the aim of providing evidenced-based solutions and key messages to strengthen cancer surgical systems, education, and research.

In the first section, we examined the global burden of surgically amenable cancers, the range of procedures that are necessary to treat cancer at all levels of complexity, and the effect that surgery has on patient outcomes. The aim of the second section was to understand the economic and financial issues surrounding cancer surgery; how are patients affected? How can countries deliver affordable surgical systems for cancer, and how should this be regulated? Both of these sections set the scene against which we then explored the complex issue of strengthening surgical systems in different resource settings. We have approached this issue through in-depth country studies and a cross-cutting analysis of the horizontal determinants of systems strengthening, both of which inform the proposed scale-up model and the recommendations for education and training. We also recognised the importance of research, and we dedicated the fourth section to an in-depth analysis. Finally, we placed the issues and solutions for global cancer surgery in the political context of global health and summarised the key messages from this Commission.

Section snippets

Global need for cancer surgery

Measurement of the burden of cancer in a population is essential for delivery of safe, affordable, and timely cancer surgery. Reliable estimates of the cancer burden can provide a comprehensive picture of the variation between geographical areas and population strata. These estimates, in turn, inform the development of cancer control strategies and surgical systems strengthening, as well as economic assessments. Increasingly, survival, mortality, and incidence trends are also being used to

Economics and financing of cancer surgery

The ability to deliver safe, affordable, and timely cancer surgery to all is crucially dependent on economics and financing, particularly investment policies that are framed by national and international regulation and law (panel 1). We examined these areas with a view to asking what policymakers should be undertaking in terms of investment and financial risk protection for patients with cancer who are undergoing surgery, and how could, or should, the law be used to ensure both fiscal probity

Strengthening surgical systems for cancer

In Global Surgery 2030,2 the factors needed to build surgical systems to deliver surgery to some of the world's most vulnerable populations were described. Building on this, we explored the issues and solutions for strengthening cancer surgical systems across resource settings through generic cross-cutting dimensions, and across specific countries, stratified by income setting.

Research and global cancer surgery

We examined key aspects of global research into cancer surgery, both from a qualitative and quantitative perspective. We also examined how cancer surgery is integral to the wider cancer research agenda. This view is framed by an in-depth analysis of the current state of global cancer surgery,155 specifically to understand the gaps, opportunities, and innovations for cancer surgery over the next decade.

Political framing of global cancer surgery

To deliver cancer surgery to all, international and national cancer control planning needs to address several political issues to ensure the effective translation of evidence into practice. Despite substantial recent political and policy activity directed at non-communicable diseases, and cancer in particular, surgery has not been a prioritised area for organisations and advocacy. Generation of a political priority for global cancer surgery is crucial to increase investment and build systems of

Conclusions

Equity, shared responsibility, and quality cancer surgical delivery to patients, irrespective of ability to pay, are the goals of global cancer and global cancer surgery. This is only achieved via universal health coverage—probably the most widely shared goal in global health. This Commission has described the economic, regulatory, and systems issues and solutions to global cancer surgery. But more is needed to understand transferable systems and models of care, health intelligence to properly

Search strategy and selection criteria

References for this Commission were identified through searches of PubMed, Web of Science, Scopus, and grey literature (Google) with the search terms “cancer”, “region definitions/country definitions”, “surgery”, “oncology”, “human resource”, “capacity building”, and “policy” from Jan 1, 1998, to Aug 31, 2015, in various combinations. Articles were also identified through searches of the commissioners' own files and through an extensive bibliometric analysis, as described in the appendix

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