Cancer Surgery Crisis — Urgent Action Needed

Liam Davenport

September 28, 2015

VIENNA — Surgery has a bigger impact on cancer than any other treatment modality, with potential to cure more than 50% of patients, and yet worldwide, fewer than 25% of cancer patients have access to safe and affordable care.

There is a huge shortfall in the worldwide provision of cancer surgery, say experts, and they suggest that a combination of research, improvements to surgical systems, and the incorporation of surgery into national cancer plans is needed to tackle the crisis.

The shortfall is revealed in a major analysis presented here at the European Cancer Congress 2015 and published simultaneously in Lancet Oncology as part of a Commission on access to cancer services. It found that worldwide, less than 25% of cancer patients have access to safe, affordable surgery, while in low-income countries, up to 95% do not receive basic surgical care.

With cancer incidence rates rising as people live longer, the number of procedures needed annually is set to reach 45 million. However, without major investment, three-quarters of cancer patients in low- and middle-income countries (LIMCs) are expected to die from cancer in 2030, compared with less than half in high-income countries.

Together, the cumulative losses to the global economy resulting from a lack of surgical care could top $20 trillion, or 1.3% of the projected global economic output.

"This Commission clearly outlines the enormous scale of the problem posed by the global shortfall in access to cancer surgery and current deficiencies in pathology and imaging," said Richard Sullivan, MD, PhD, Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, King's College London, United Kingdom, in a release.

"The evidence outlined by the Commission, contributed by some of the world's leading experts in the field, leaves no doubt of the dire situation we are facing. It is imperative that surgery is at the heart of global and national cancer plans," he said.

"A powerful political commitment is needed in all countries to increase investment and training in publicly funded systems of cancer surgery," Dr Sullivan emphasized.

However, there is hope for the future. "The good news is that surgery is effective and surgery is cost-effective.... In fact, it's the most cost-effective treatment," coauthor Riccardo Audisio, MD, FRCS(Engl), consultant surgical oncologist and honorary professor at the University of Liverpool, United Kingdom, and president of the European Society of Surgical Oncology, said during a press briefing.

"The bad news, unfortunately, is that only one in five surgery patients will receive the appropriate surgical treatment," he added.

Discussing how to bridge that gap, he said: "It all revolves around setting guidelines or, if you want, instead of dreaming of guidelines that cannot be implemented because of the local facilities, we are looking to establish minimum standards, and 'minimum standards' is something that needs to be accomplished from the top academic places to the very basic institutes."

More Than 80% Cancers Need Surgery

To develop the Commission, the authors used published evidence, such as the findings from Global Surgery 2030, commissioner meetings, and original analyses to examine the state of surgery globally and across all income settings. The aim was to produce evidence-based solutions to strengthen cancer surgical systems, education, and research.

The analysis showed that, of the 15.2 million cancer cases diagnosed worldwide in 2015, more than 80% will need surgery. Of the new cancer cases, 57% will have occurred in LMICs. Moreover, of the 8.8 million cancer deaths predicted for 2015, 65% will have occurred in LMICs.

The Commission found, however, that less than 25% of cancer patients worldwide have access to safe, affordable surgical care when it is needed, with only 5% of patients in low-income countries and 22% of those in middle-income countries having access to basic cancer surgery. There is also a serious shortage of cancer surgeons in 82% of countries.

By 2030, it was projected there will be 21.6 million new cancer cases, of whom 17.3 million will require surgery and 10.0 million of whom will be from LMICs. Overall, 45 million cancer surgery procedures will be needed annually. It is also expected that 75% of cancer patients in LMICs will die in 2030, compared with 46% of those in high-income countries.

Without urgent investment in cancer surgery services, the Commission argues, the global economic losses from cancers that could have been treated by surgery will total $12 trillion in 2030. The proportional impact of this loss equates to an annual loss of gross domestic product (GDP) of 1.0% to 1.5% in high-income countries and 0.5% to 1.0% in LMICs.

When looking at the impact of cancer morbidity and mortality in terms of the value of statistical life, which can be equated to financial losses, it was calculated that the global annual economic welfare losses are estimated at $7 trillion for surgical cancer mortality and $400 billion for surgical cancer morbidity. This represents an annual loss of GDP of 10% and 6% in high- and upper-middle-income countries, respectively.

The researchers also emphasized that there are micro-, as well as macro-, economic losses resulting from a lack of access to surgery for cancer patients. For example, a study of out-of-pocket costs, catastrophic expenditure, and discontinuation of treatment in more than 4500 patients in Southeast Asia revealed that 31% of patients with surgically operable cancer experienced financial catastrophe and 23% discontinued treatment.

Solutions — "Not One-Size-Fits-All"

Turning to potential solutions for the issues that the Commission identified, Dr Sullivan said: "Well, first of all, it's about building systems, and this is not a one-size-fits-all."

"We're talking around 277 different surgical procedures across six complexity levels. At least 110 of those require specialist cancer surgeons, in gynecological oncology, urology, head and neck.... So it's different horses for different courses," he said.

"The first thing we call for, of course, is to have surgery integrated into national cancer control plans [NCCPs]," he said, and many more of these are needed. "When we looked at NCCPs which are out there at the moment, only about 50% of countries globally have NCCPs.

"Only 9% of those programs actually have elements that you could identify as developing capacity and capability in cancer surgery, and that needs to radically increase," he explained.

However, Dr Audisio commented, "policy makers at all levels still have little awareness of the central importance of surgery to cancer control. Even recent studies of capacity building for cancer systems in Africa barely acknowledged the importance of surgery, focusing mainly on chemotherapy instead."

Massive Deficit in Research

Another important aspect that the Commission identified for improving surgical oncology was research. "The analysis...shows that, globally, the amount of research dedicated to cancer surgery is less than 5%, which is unbelievable, but it's true," said Dr Sullivan.

"Most of the money at the moment goes into fundamental research, and you won't be surprised [that it's for] medicines and biomarkers. The reality is that for radiation, surgery, palliative care, we come a long way down the list."

He added: "Even more worrying for the future is a that lot of this research is focused in high-income countries. So, of the totality of surgical cancer research, only about 17% is relevant to a lot of the emerging and low-income economies. That's a massive deficit in research."

The Commission estimated that just 1.3% of the annual global cancer research and development budget goes toward surgery. Moreover, 93.0% of global research in cancer surgery is carried out by only 34 of 195 countries.

Nevertheless, Dr Audisio does not believe that clinical trials per se are the best way of plugging the research gap.

"You need to know that only less than 2% of the cancer population is entering trials, and this skews the results, because it's not representative of the real population," he said.

"It's not representative because, when compared to real patients, these patients are different. They are more educated, they've got less aggressive treatment, they are better nourished, and so on."

Dr Audisio continued: "The findings are therefore different and, most importantly, trials with negative findings are never published, so what do you do? You look at the results of several trials to make a meta-analysis, but, by definition, you forget the negative trials that you don't consider in your meta-analysis because they are not worth mentioning."

He noted that observational studies of real-world outcomes have shown that surgical procedures can achieve up to 50% survival in cancer patients.

"So you don't need the trial; you have huge evidence that this is what is working," Dr Audisio said. "The trial mentality only works when you don't have end results to sell, when you cannot convince your providers that it's worth investing a huge amount of money into a treatment which is achieving 3-month, 6-month local disease-free gains."

We're talking curing over 50% of cancer patients.

Referring to the differences in outcomes between surgery and "a new molecular magic bullet," he said: "We are talking curing patients. We're not talking delaying for months or weeks, we're talking curing over 50% of cancer patients. That's a strong message."

He added: "It's not extending survival or improving wellbeing, this is saving human lives. This is something which is not being taken into account."

Summarizing, Dr Audisio said: "I am very grateful for being given the opportunity to run up the surgical oncology flag and to remind the community how crucially important [it] is."

Coauthor Mark Shrime, MD, from the program in global surgery and social change at Boston Children's Hospital, Harvard Medical School, reports received personal fees from Ethicon.

European Cancer Congress (ECC) 2015: Abstract LBA9. Presented September 28, 2015.

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