Postoperative Mortality and Complications After Cancer Surgery

Quick Takes

  • This prospective, international cohort study found that the 30-day postoperative mortality following surgery for breast, colorectal, or gastric cancer was 4 times higher in resource-limited settings despite similar complication rates, attributable to both patient-specific and health system factors.
  • The absence of available postoperative care facilities was associated with 7-10 more deaths per 100 major complications in low-income and middle-income countries.
  • The authors concluded that the capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention.

Study Questions:

What are the effects of disease stage and complications on postoperative mortality among patients with breast, colorectal, or gastric cancer undergoing surgery in hospitals worldwide?

Methods:

This was a multicenter, 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 anesthesia. 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.

Results:

A cohort of 15,958 patients were enrolled from 428 hospitals in 82 countries (high income: 9,106 patients from 31 countries; upper-middle income: 2,721 patients from 23 countries; lower-middle income: 4,131 patients from 28 countries) between April 1, 2018 and January 31, 2019. Patients in low-income and middle-income countries (LMICs) presented with more advanced disease compared with patients in high-income countries. Thirty-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio [OR], 3.72; 95% confidence interval [CI], 1.70-8.16), and for colorectal cancer in low-income or lower-middle-income countries (adjusted OR, 4.59; 95% CI, 2.39-8.80) and upper-middle-income countries (adjusted OR, 2.06; 95% CI, 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 (adjusted OR, 6.15; 95% CI, 3.26-11.59) and upper-middle-income countries (adjusted OR, 3.89; 95% CI, 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 7-10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

Conclusions:

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The authors concluded that the capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention, and that early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

Perspective:

Breast cancer, colorectal cancer, and gastric cancer are common causes of cancer-related mortality and morbidity worldwide. Of 15.2 million people worldwide diagnosed with cancer in 2015, 80% underwent surgery, an important therapy for cancer cure and palliation. Differences in cancer outcomes in LMICs compared to high-income countries often are attributed to a more advanced stage of presentation and absent access to cancer-specific treatments. This prospective, international cohort study found that the 30-day postoperative mortality following surgery for breast, colorectal, or gastric cancer was 4 times higher in resource-limited settings despite similar complication rates, attributable to both patient-specific and health system factors; and that the absence of available postoperative care facilities was associated with more deaths in LMICs following major surgical complications. In addition to efforts aimed at the early detection and treatment of cancer, cancer outcomes in LMICs can be improved through investments in improved perioperative care.

Clinical Topics: Cardio-Oncology, Prevention

Keywords: Anesthesia, Breast Neoplasms, Cardiotoxicity, Colorectal Neoplasms, Developed Countries, Developing Countries, General Surgery, Hospitals, Income, Morbidity, Neoplasms, Outcome Assessment (Health Care), Postoperative Care, Postoperative Complications, Poverty, Secondary Prevention, Stomach Neoplasms


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