Meeting the Global Cancer Surgery Demand through Research & Innovation

We congratulate Perera et.al for the in-depth analyses on the increasing global demand for cancer surgery and its required workforce by 2040 (1). The greatest increases in this burden are projected to occur disproportionately among low- to middle-income countries (LMICs). Critical issues were highlighted: absence of investments on infrastructures to deliver high quality surgical care, increase of healthcare workers needed to meet the demand and training optimisation of future specialists. They used validated modelling methods for these projections but procedures beyond the index surgical treatment, impact of evolving strategies for escalation or de-escalation of cancer surgeries and implications of delayed cancer diagnoses and treatment during the pandemic were not yet considered.

Increasing the surgical workforce as it confronts its own vulnerabilities will be challenging. The COVID-19 pandemic exposed the fragility, burnout and sense of hopelessness among healthcare workers. Wholistic training programs to hone competent and emotionally resilient specialists will need to be redefined and strengthened. Opportunities to encourage excellence and work-life balance especially for women pursuing surgery and anaesthesiology should be the standard. The workforce cannot just increase in numbers. They must be empowered.

The highest surgical demand by 2040 will be seen among the most difficult cancers and will affect under-resourced countries disproportionately (1). Higher levels of postoperative mortality also occur in LMICs yet, there is a misalignment in research priorities, funding, and rapid dissemination of trial results which are focused on drug development and driven by a high-income country agenda (2–4). While innovations in this field are important, their benefits do not easily reach LMICs where surgery remains as the essential and most accessible cancer treatment (5,6). Hence, cancer surgery research must be prioritised. This remains challenging but there is hope (3,7). Academic groups like the GlobalSurg Collaborative are performing international research activities that address surgical issues especially relevant among LMICs, combining a grassroots approach with innovative use of social media and bioinformatics (4,8,9). Such efforts are generating solid evidence that can refine current guidelines and optimise cancer care (9,10). Promoting mentorship, capacity building and knowledge sharing initiatives between high and LMICs institutions can foster collaboration and help close some of these gaps (3).

To meet the increasing global demand for cancer surgery, we urgently need a multidimensional approach to improve infrastructures, empower people and heal the wounded spirit of today’s surgical workforce. For two Filipino women surgeons engaged in global cancer research, this call for action is especially significant: to prevent cancer deaths in the world’s most vulnerable regions by informing and enabling high quality surgical care.

References

1. Perera SK, Jacob S, Wilson BE, et al. Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040 : a population-based modelling study. Lancet Oncol. 2021;22(2):182-189. doi:10.1016/S1470-2045(20)30675-6

2. Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015;16(11):1193-1224. doi:10.1016/S1470-2045(15)00223-5

3. Gyawali B, Bouche G, Crisp N, Andre N. Challenges and opportunities for conducting clinical trials in low- and middle-income countries. Nat Cancer. 2020;1(February):142-145. doi:10.1038/s41372-019-0470-2

4. Knight SR, Shaw CA, Pius R, et al. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet. 2021:387-397. doi:10.1016/S0140-6736(21)00001-5

5. Marseille E, Morshed S. Essential surgery is cost effective in resource-poor countries. Lancet Glob Heal. 2014;2(6):e302-3. doi:10.1016/S2214-109X(14)70236-0

6. Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Heal. 2014;2(6):e334-45. doi:10.1016/S2214-109X(14)70213-X

7. Søreide K, Alderson D, Bergenfelz A, et al. Strategies to improve clinical research in surgery through international collaboration. Lancet (London, England). 2013;382(9898):1140-1151. doi:10.1016/S0140-6736(13)61455-5

8. Bhangu A, Kolias AG, Pinkney T, Hall NJ, Fitzgerald JE. Surgical research collaboratives in the UK. Lancet (London, England). 2013;382(9898):1091-1092. doi:10.1016/S0140-6736(13)62013-9

9. Bhangu A, Ademuyiwa AO, Aguilera ML, et al. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis. 2018.

10. Nepogodiev D, Adisa A, Abantanga FA, et al. Delphi prioritization and development of global surgery guidelines for the prevention of surgical-site infection. Br J Surg. 2020;107(8):970-977. doi:10.1002/bjs.11530