Global Cancer Surgery in Low-resource Settings: a Strengths, Weaknesses, Opportunities, and Threats analysis

Abstract

Global cancer surgery is an essential and complex component of oncologic care. This study aims to describe global cancer surgery literature since the 2015 Lancet Commission on Global Surgery and Cancer Surgery and perform a SWOT analysis. A systematic search was performed in PubMed of global cancer surgery articles. Themes were extracted from the included studies based on the following criteria: (1) performed in low- or low-middle-income countries, (2) published during or after 2015, (3) published in peer-reviewed journals, (4) written in the English language, and (5) accessible to the authors. Themes were further groups into strengths, weaknesses, opportunities, and threats (SWOT analysis). The search strategy identified 154 articles published from 1992 to 2022. Forty-six articles were included in the qualitative synthesis and SWOT analysis. Recurring themes included local epidemiologic studies, local innovations and feasibility studies, prioritizing quality of life outcomes, multidisciplinary team approaches, limited resources, health system gaps, lack of economic analyses, diverse cancer management strategies and priorities, inter-setting collaboration, research expansion, the COVID-19 pandemic, and unchecked technological advancements. These strengths, weaknesses, opportunities, and threats were described and related to the themes of research, surgical systems strengthening, economics and financing, and political framing of the 2015 Lancet Commission on Global Cancer Surgery. SWOT analyses of global cancer surgery may be helpful in suggesting future strategies for this expanding field.

Precis:

Global cancer surgery is an essential and expanding field in low resource settings. Performing a SWOT analysis of global cancer surgery may aid its growth in multiple areas.

Lay Summary:

Cancer surgery is a resource-intensive yet essential component of cancer care. In the face of projected growth of cancer burden, the present gap in cancer surgery care in low-resource settings with stressed healthcare and surgical infrastructure risks further exacerbation. We present a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of recent global cancer surgery literature pertaining to low-resource settings.

Background

The burden of cancer continues to grow globally, but not evenly. The 2019 Global Burden of Disease (GBD) study demonstrated that the burden of cancer is growing at a disproportionately high rate in areas with a lower socio-demographic index (SDI), a composite indicator of income per capita, average years of education and total fertility rate of females under 25 years-of-age ^{1, 2}. From 2010 to 2019, countries in the low and low-middle SDI quintiles demonstrated the largest increase in annualized rates of change of the absolute numbers of cancer cases and deaths, as well as the age-standardized rates of mortality from, and incidence of, cancer. Morbidity and mortality due to cancer translates into an economic burden, which likewise disproportionately falls on low-resource countries ³.

Cancer surgery is an essential yet complex component of oncologic care. Surgery is used to achieve various goals in cancer management depending on timeline, symptoms, complications, and the nature of the cancer itself. Surgery plays a critical role in diagnosis, treatment, prevention, monitoring, reconstruction and functional restoration, and management of complications of cancer. For example, individuals discovered to have certain genetic predispositions to breast, colon, thyroid and/or gastric cancers may benefit from prophylactic surgical management ^4–6. Preventative surgery includes early intervention with the discovery of precancerous lesions deemed to have high risk of malignant transformation. This decision-making hinges on the diagnostic capacity of cancer surgery, such as through biopsy. Cancer surgery may be curative in certain cases, often possible with early detection and intervention. Surgical cancer resection can also be performed primarily for symptom alleviation, even in non-curable, palliative cases. For example, symptoms caused by the cancer itself (i.e. paraneoplastic syndromes, ascites production, pain due to tissue invasion) or by secondary manifestations of cancer size (i.e. mass effect, lumen obstruction) may be indications for removal. Finally, reconstructive surgery for functional and/or body form restoration is an important consideration when the surgical cancer resection results in a defect that impacts the patient’s quality of life.

Cancer surgery is a resource-intensive, technically-challenging practice performed for prophylactic, preventative, diagnostic, curative, palliative and reconstructive purposes. Determining the appropriate role of surgery involves informed consideration of timing, pathophysiology, and symptomatology of the specific cancer and patient’s presentation. A recent estimate suggests that over 80% of all cancers require some surgical management, resulting in an estimated global need for 32 million cancer-related operations annually in 2015 and 45 million by 2030 ⁷. More recent modeling by Perera et al. (2021) predicts a 52% increase in global surgical cancer cases between 2018 and 2040--approximately 5 million more procedures needed for cancer-related indications in 2040 compared to in 2018 ⁸. Once the decision is made to pursue cancer surgery, there are significant technological, human, monetary, and intellectual resource requirements to facilitate such care; this includes various extra-operative components such as imaging, pathology, and adjunct oncologic therapies, such as chemotherapy, radiotherapy, and immunotherapy ⁹.

Unfortunately, broad, inclusive access to cancer surgery is not a present reality. In 2015, the Lancet Commission on cancer surgery explored the global landscape of cancer surgery in terms of the global need, the economic and financial complexities surrounding its delivery (or lack thereof), mechanisms for systems strengthening, research in cancer surgery and global surgery more broadly, as well as the complex and important role of government and politics in the future of global cancer surgery ⁷. The authors estimated that only 5% of patients in low-income settings have access to adequate cancer surgery performed in a safe, timely and effective manner. The 2015 Lancet Commission on global surgery likewise asserted the importance of cancer surgery to achieve equitable health outcomes, vouching for its inclusion in certain universal health coverage packages for more holistic oncologic management ¹⁰. Ultimately, as cancer and cancer surgery caseloads are expected to increase disproportionately in low-resource settings ^{11, 12}, capacity-building for cancer surgery is essential for promoting equitable cancer treatment and outcomes globally ^{13, 14}.

Engagement by key stakeholders is important to foster effective, sustainable, and resilient improvements in cancer surgery performance and outcomes. From the perspective of a given operative setting, these stakeholders include but are not limited to: the patients, patient families, local cancer surgery care providers (i.e. surgeons, other staff) and their multidisciplinary care-providing partners (i.e. pathology, radiology), local academic and healthcare institutions, local health policy-makers and relevant political figures, international research and training partners, and industry. With these key stakeholders in mind, it is important to understand the current state of cancer surgery in low-resource settings and associated interventions.

The objectives of this report are to (1) describe the landscape of global cancer surgery literature since the 2015 Lancet Commission on Global Surgery and Global Cancer Surgery and (2) characterize the global cancer surgery field through a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis to inform future research and interventions.

Methods

An electronic literature search was performed on April 5, 2022 in PubMed using the search terms (“cancer surgery” OR “oncological surgery” OR “oncologic surgery” OR “surgical oncology” OR “tumor surgery”) AND (“low resource” OR “LMIC” OR “low income” OR “developing country” OR “developing nation”). Medical Subject Headings (MeSH) and non-MeSH terms were applied with filters utilized to reject studies published before January 1, 2015. The compiled reference list was reviewed for relevance. The reference lists of published studies and reviews were also examined to identify additional studies. The primary themes of interest were strengths, weaknesses, opportunities, and threats that affect Global Cancer Surgery stakeholders in low-resource settings. Included studies of Global Cancer Surgery met the following criteria: (1) performed in low-resource settings, which this review defined as low- or low-middle-income countries as defined by the World Bank for the 2023 fiscal year, or published in collaboration with low- to low-middle income countries; (2) published during or after 2015, the year the Lancet Commission on Global Cancer Surgery report was published; (3) published in peer-reviewed journals; (4) written in the English language; and (5) accessible to the authors. Excluded from consideration were studies about global surgery that did not treat cancer and studies describing cancer treatment without a surgical cancer focus. The following data were extracted and reported: first author and year of study, country, World Bank income classification for the 2023 fiscal year, whether the article was open access, study type, cancer type(s) and intervention(s) included. Studies were summarized and evaluated for themes, which were further grouped into strengths, weaknesses, opportunities, and threats (SWOT analysis).

Results

Our search strategy identified 154 articles published from 1992 to 2022. Of these, 123 articles were published during or after 2015. The inclusion and exclusion criteria were then applied to the titles and abstracts yielding 71 articles. These articles underwent full-text analysis resulting in 46 articles included in quantitative analysis, qualitative synthesis, and SWOT analysis (Table 1). The majority of included studies were published in 2021 and 2022 (n=26) (Figure 1). Thirty-four articles were open access (Table 1).

Table 1.

Description of studies produced and included by electronic literature search. The 46 articles that met inclusion criteria for analysis are listed here. For each article, the following descriptive data is included where applicable: first author, year, open access (yes/no), study type, country/countries (i.e. low-resource settings in which these studies were performed or pertain to) and the corresponding World Bank income classification(s), and the included cancer(s) and/or intervention(s).

First Author	Year	Open Access (Yes/No)	Study Type	Country/ Countries	World Bank Income Classification	Cancer(s)	Intervention(s)
Amin AT	2015	Yes	Case series	Egypt	LMIC	Colorectal	Laparoscopic colectomy
Khan MK	2015	Yes	Retrospective cohort	Pakistan	LMIC	Gastric	Subtotal gastrectomy, total gastrectomy, splenectomy with/without distal pancreatectomy (“total plus gastrectomy”)
Rukewe A	2015	Yes	Case Report	Nigeria	LMIC	Breast	Single-shot lamina technique of paravertebral block
Bhatt A	2017	Yes	Case series	India	LMIC	Peritoneal métastasés	cytoreductive surgery, hyperthermic intraperitoneal chemotherapy (HIPEC)
Martin AN	2018	Yes	Restrospective cohort	Rwanda	LIC	Gastric	palliative (Gastrojejunostomy, exploratory laparotomy/primary perforation repair); curative (distal gastrectomy, other gastrectomy, Billroth I or II reconstruction)
Youssef MMG	2018	Yes	Prospective Cohort	Egypt	LMIC	Breast	Oncoplastic breast surgery, axillary staging procedure
Ayandipo OO	2019	No	prospective cohort study	Nigeria	LMIC	Breast (primary) with cerebral métastasés	craniotomy (infra- and supratentorial)
Ekdahl Hjelm T	2019	Yes	Retrospective cohort	Uganda	LIC	Breast	Tumor/breast excisions, debulking/debridement, quadrantectomies, lumpectomies, simple-, radical- and palliative/toilet mastectomies
Khalil MAI	2019	Yes	Retrospective Cohort	Pakistan	LMIC	Renal cell carcinoma, angiomyolipoma, pseudotumor	Partial nephrectomy
Almas T	2020	Yes	Retrospective cohort	Pakistan	LMIC	Various (soft tissue) sarcomas	Wide local excision, compartmental excision
Asfour HY	2020	Yes	Retrospective Cohort	Egypt	LMIC	Wilms’ tumor	Nephrectomy, lymph node sampling
De Oliveira, AJM	2020	Yes	Retrospective Cohort	Angola	LMIC	Multiple	Surgical training in Brasil for Angolan doctors through the Cooperation Program for Foreign Doctors (PCME)
Debas H	2020	No	Clinical Practice Guidelines	Multiple	Includes LMICs	Multiple	Guiding principles for equitable, sustainable, and effective partnerships between low- and high-resource settings by the American Surgical Association Working Group for Global Surgery
Deepa KV	2020	Yes	Survey	India	LMIC	Breast	Breast conservation surgery
Elghazawy H	2020	Yes	Review	Egypt, Morocco, Saudi Arabia, Jordan	Includes LMIC	Breast	Multiple
Fiaz S	2020	Yes	Retrospective Cohort	Pakistan	LMIC	Bladder	Radiotherapy and Radical Cystectomy
Jamal A	2020	No	Retrospective Cohort	Pakistan	LMIC	Pancreatic, periampullary, duodenal	Pancreaticoduodenectomy
Kumar N	2020	Yes	Retrospective Cohort	India	LMIC	Vulvar	Wide local excision, bilateral inguinofemoral dissection, primary repair; radical vulvectomy; modified radical vulvectomy with or without lymph node dissection; reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps; therapeutic groin nodal dissection
Naeem A	2020	Yes	Retrospective Cohort	Pakistan	LMIC	Colon	laparoscopic right or extended right hemicolectomy
Rizvi FH	2020	Yes	Cohort	Pakistan	LMIC	Breast	level II axillary lymph node dissection (all patients); breast-conserving surgery (BCS), modified radical masectomy (MRM)
Akhtar N	2021	Yes	Retrospective Cohort	India	LMIC	Multiple	N/A
Deo S	2021	Yes	Retrospective Cohort	India	LMIC	Multiple	HIPEC
Deo SVS	2021	Yes	Retrospective Cohort	India	LMIC	Gastro-oesophageal, colorectal, breast, gynaecological, musculoskeletal, head-and-neck, hepatobiliary	Multiple
Deo SVS	2021	Yes	Retrospective Cohort	India	LMIC	Colorectal	N/A
Fadlalla WM	2021	Yes	Randomized controlled trial	Egypt	LMIC	Bladder	Laparoscopic radical cystectomy, open radical cystectomy
Kamarajah SK	2021	No	Prospective Cohort	Multiple	Includes LMICs	Esophageal	Esophagectomy
Kaul P	2021	No	Retrospective case series	India	LMIC	Oral	Reconstructions of Large and Complex Oral Cavity Defects Using Extended Bipaddle Pectoralis Major Myocutaneous Flaps
Knight SR	2021	Yes	Prospective Cohort	Multiple	Includes LICs & LMICs	Breast, Colorectal, Gastric	Multiple
Majbar MA	2021	No	Retrospective cohort	Morocco; France as comparison	Includes LMIC	Colorectal	colo-anal anastomoses (delayed, classical)
Malik AA	2021	No	Clinical Practice Guidelines	Pakistan	LMIC	Colorectal	Multiple
Mishra V	2021	Yes	Retrospective Cohort	India	LMIC	Oral squamous cell carcinoma	N/A
Naveed S	2021	Yes	Retrospective Cohort	India	LMIC	Gallbladder	Radical cholecystectomy, lymph node ratio
Ndlovu N	2021	Yes	Report	Zimbabwe, Cameroon, Nigeria, Tanzania, Kenya	LMICs	Multiple	N/A
Perera SK	2021	No	Cross-sectional study	Multiple	Includes LICs & LMICs	Multiple	Multiple
Ranganathan K	2021	No	Review	Multiple	Includes LICs & LMICs	Breast	N/A
Ranganathan P	2021	Yes	Review	India	LMIC	Multiple	Multiple
Sohail S	2021	Yes	Retrospective Cohort	Pakistan	LMIC	Adrenocortical carcinoma	Radical adrenalectomy
Arshad A	2022	Yes	Cohort	Pakistan	LMIC	breats, parotid, oesophagus, chondosarcoma cancers with metastatic spine disease	Posterior surgical decompression and fixation of the spine.
Chargari C	2022	No	Review	Multiple	LMICs	Cervical	Resection, lymph node dissection
DeBoer RJ	2022	Yes	Retrospective Cohort	Rwanda	LIC	Cervical	Radical hysterectomy, chemoradiation, upfront chemotherapy
Hornstein P	2022	Yes	Cross-sectional	Multiple	Includes LICs & LMICs	Multiple	N/A
Houssaini K	2022	No	Retrospective Cohort	Morocco	LMIC	Hepatocellular carcinoma	Liver resections
Rashad N	2022	Yes	Consensus guidelines	Egypt	LMIC	Colorectal	N/A
Selmouni F	2022	No	Prospective Cohort	Morocco	LMIC	Colorectal	Fecal immunochemical test
Souadka A	2022	Yes	Cross-sectional	Morocco, Algeria, Tunisia, Mauritania, Libya	Includes LMICs	Ovarian, Gastric, Colorectal, Pseudomyxoma peritonei	Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.
Vohra LM	2022	Yes	Retrospective Cohort	Pakistan	LMIC	Breast	N/A

Figure 1.

Included publications by year published. The online literature search yielded 123 articles, of which 46 articles met inclusion criteria for analysis. The majority of included studies were open access (n=34) and published between 2021 and 2022 (n=26).

A SWOT analysis was performed utilizing the themes gathered from the included studies to further illustrate current cancer surgery research in resource-limited areas; brief descriptive summaries of key identified themes were synthesized and tabulated (Figure 2). Below, we elaborate on aspects described in the SWOT table that are not otherwise described in the background.

Figure 2.

SWOT analysis of the current global cancer surgery landscape. A literature review was performed of global cancer surgery studies involving low-resource settings published since the landmark 2015 Lancet Commission on Global Surgery and Global Cancer Surgery. Key findings and themes from the included papers were characterized through a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis.

Strengths

Local epidemiologic studies

Studies describing the local landscape of cancer surgery burden, caseload, operative techniques, outcomes, and barriers are foundational to identifying key intervention targets and to evaluating change over time ^{15, 16}. On a more “microscopic” level, recent studies highlighting differences in tumor pathology and epidemiology between settings have yielded important insights ^17–21. A study among Indian patients status-post radical cholecystectomy for gallbladder carcinoma supported the utility of evaluating lymph node involvement for determining prognosis ¹⁹. While some of the cancers investigated may be considered rare, these studies provide critical context for targeted design and informed assessment of effective local interventions.

Local innovations and feasibility studies

A number of studies in low-resource settings have investigated the feasibility of utilizing certain intraoperative techniques, equipment and other technological advancements which have been previously proven effective in higher-resource settings. It should be noted that many (but not all) of the feasibility studies discussed in this section used small sample sizes and/or were performed at a single, high-volume cancer center; this raises questions, for example, about the generalizability of study findings across variable patient populations or among smaller community hospitals, which may more accurately represent the average care received within a given country. It is important to appreciate that these study design limitations in many ways reflect the local resource limitations of low-resource settings and thus provide contextual value for future studies. A few key studies are highlighted below.

Since the 2015 Lancet Commission on Global Surgery, a number of studies on the feasibility and safety of surgical procedures for several cancers including orofacial, gastrointestinal, urological, gynecological, breast, brain, and spine tumors have been performed in countries including Egypt, India, Nigeria, Pakistan, and Taiwan ^22–36. It is notable that most of these studies were performed at a single institution, with multicenter collaborative studies being rare. Surgical interventions described mostly include resections which aim to maximize overall survival and progression-free survival such as pancreaticoduodenectomy, gastrectomy, hepatectomy, cytoreductive surgery, laparoscopic colorectal surgery, radical cystectomy, partial nephrectomy, and brain and spine tumor removal. A number of techniques were described with an alternative primary goal of improving quality of life, such as oncoplastic surgery, breast-conserving therapy, spine stabilization ^{23, 28, 31, 36}; this concept is further explored in the following section.

Critical to the success of many complex surgical procedures in oncology is the integration of technological advancements into low-resource surgical settings. For example, a few studies investigated the feasibility of implementing laparoscopic surgery in lower-resource settings ^{22, 37}. The ongoing costs involved with laparoscopic equipment is significant due to the need for single use components. Thus, one study determined that reusing certain components of laparoscopic equipment deemed “single-use” for colectomies by the manufacturer may be a feasible option to reduce costs and increase access to these operations ²².

Creating cost-effective alternatives for existing technologies is also a target of research interest. Application of hyperthermic intraperitoneal chemotherapy (HIPEC) was also described ^{25, 26, 38}, with some institutions demonstrating a capacity to locally engineer their own HIPEC machines. A group in India created a “homemade” HIPEC machine that reduced the cost of consumables to less than a third of that of commercially available products while demonstrating similar patient outcomes ²⁵. Thus, feasibility studies on local adaptation of technological advancements in surgery are important to reducing cost and securing more equitable access to standard-of-care surgical procedures ^{23, 39, 40}.

Finally, cancer surgery facilities and system operations also offer a target for improvement. For example, surgical oncologists in a Moroccan tertiary cancer center implemented a series of quality improvement interventions targeting inter-staff communication, electronic patient data management, treatment protocol development, and morbidity and mortality reviews ⁴¹. In the following year, there was a significant decrease in severe postoperative complications from liver resections for primary tumors or metastases. This study suggests a positive relationship between improving administrative and interpersonal functions and patient safety, which may be achieved through applying organizational practices, technological advances or other quality improvement interventions.

Prioritizing quality of life outcomes

Feasibility studies in cancer surgery from LMICs have expanded to cover not only survival outcomes but also quality of life measures. A qualitative approach to evaluating surgical oncology effectiveness and to guiding interventions is the relative impact on patient quality of life. Cancer surgery can be performed for a wide range of urgent and nonurgent indications, the latter including surgical procedures performed for palliative or reconstructive purposes. Preserving or improving a patient’s quality of life is a critical function and consideration of cancer surgery ⁴² and therefore an important consideration in providing equitable surgical cancer care ²⁸. Palliative cancer surgeries may be particularly important in low resource settings due to a higher burden of advanced, and therefore more symptomatic disease ⁴³. A study in India demonstrated feasibility and effectiveness of palliative operations for a variety of cancer patients, with the vast majority of patients endorsing subsequent symptomatic relief ¹⁸. However, post-operative morbidity is an important consideration for any procedure, especially for patients with limited financial resources, health literacy, or access; weighing these risks and benefits necessitates a case-by-case determination and discussion with the patient and family.

Surgery for breast cancer carries a particularly sensitive physical burden, and thus a number of studies in LMICs have investigated the feasibility and effectiveness of various surgical approaches ^{31, 35, 36, 44}. Two options for breast cancer surgery include (modified radical) mastectomy, which often involves removing the entire breast, and breast-conserving surgery, in which the cancerous tissue is removed selectively to minimize the loss of normal breast tissue; thus, the mastectomy approach causes a more drastic physical alteration than a more targeted, “breast-conserving” approach. The recommended type of surgery varies based on a combination of clinical findings and patient preferences.

While overall self-reported quality of life scores among women receiving either surgical treatment may be similar, breast-conserving approaches may be associated with improved body image ^{36, 44}. Further, a study in Egypt found that implementing oncoplastic, breast-conserving techniques in the primary surgical treatment of breast surgery was a feasible way of improving patient satisfaction and achieving appropriate resection margins, which may reduce the need for future procedures ³¹. Rizvi et al. (2020) further demonstrated no difference in complication rates between patients receiving modified radical mastectomy and breast conserving surgery in Pakistan ³⁵.

Multidisciplinary team approaches to cancer care

Cancer is a complex disease, and thus multidisciplinary management is the standard of care for most cancers ⁴⁵. Patients frequently engage multiple specialties at different time points along the disease trajectory, including before and after surgery. Education and support for healthcare personnel who are involved in diagnosis and treatment before cancer surgery is an important aspect of multidisciplinary investment, as these may influence utilization of surgical interventions ⁴⁶. It is also important to consider the downstream effects of engaging patients at that point of their care journeys. Just as cancer surgery is inherently an interdisciplinary field, so should efforts toward achieving equitable cancer surgery outcomes be multidisciplinary in nature. For example, recognizing that pathology and radiology are integral to cancer surgery, we must not neglect extrasurgical infrastructure as we push for innovative surgical cancer approaches. Moreover, pain management and anesthesia are critical to safe interventions and reducing patient suffering. A case study from a Nigerian hospital showed that utilizing a thoracic paravertebral block as an adjunct to general anesthesia produced long-lasting post-operative pain control following radical mastectomy ⁴⁷. Importantly, usage of this block was associated with shorter lengths of stay in PACU and overall hospital stay and reduced opioid consumption. This example also highlights how inter-disciplinary collaboration to improve efficient and effective postoperative pain management can improve patient outcomes qualitatively and quantitatively.

Weaknesses

Limited resources and perioperative services

Resources are severely lacking in all aspects of cancer surgery in LMICs. Low-resource healthcare systems commonly lack adequate cancer management resources across all aspects of cancer surgery, including limited cancer workforce personnel ⁴⁸ and few cancer specialty hospitals (Arshad, 2022). Further, patients who undergo surgical cancer treatment in low-resource areas tend to have higher rates of severe postoperative complications ⁴⁹ and mortality ⁵⁰. In LMICs, poor post-operative care infrastructure was associated with seven to ten more deaths per 100 major complications ⁴⁹.

Limited essential extra-operative services, including pathology, imaging, and adjunct therapies (i.e. chemo/radio/immune/brachytherapy) pose a significant challenge to improving cancer surgery outcomes and accessibility ⁴². For example, breast-conserving surgery, an alternative to mastectomy whose importance is explored earlier in this piece, is usually followed by radiation therapy to the remaining breast tissue, if available. Mastectomy may be otherwise be recommended in the absence of available radiation therapy for appropriate margins. Unfortunately, radiation therapy is exceedingly difficult to access in low- versus high-resource settings. In Africa, for example, low-income countries have so few megavoltage machines (MVM) for radiation therapy that there are 39.8 million people per MVM, orders of magnitude higher than the Atomic Energy Agency’s recommendation of 250,000 people per MVM ⁵¹. While this is perhaps the most drastic example, this trend is consistent in lower-middle income countries in both Africa and Latin America, whose populations are served by 2.47 and 1.64 million people per MVM, respectively. Of note, data from lower-resource settings in the Middle East, South Asia, and Southeast Asia were limited in this study.

Other proposed barriers to improved cancer surgery access, facilitation, and outcomes in low-resource settings include, but are not limited to: delayed presentation due to geographic isolation and transportation challenges ⁵² and sociocultural and sociopolitical factors, which ultimately increases care cost and complexity ⁵³; unaffordable out-of-pocket costs ⁵⁴ which may disproportionately affect individuals in low-resource settings ⁵⁵; poor national cancer and cancer surgery registries, which may hinder accurate estimations of cancer surgery gaps and needs ^{7, 16, 43}.

Broader health system gaps

Indirect approaches, which emphasize external systems or policies that influence surgical cancer care, have also been a source of interest to researchers. For example, a study in Morocco sought to improve early cancer detection rates by providing point-of-care fecal immunochemical testing at primary health centers and offering colonoscopies for those who tested positive ⁵⁶; however, only 62.6% of those who tested positive successfully underwent a subsequent colonoscopy, with many patients citing logistical and financial barriers to attending the follow-up procedure and appointments. Furthermore, the increased burden on the Moroccan surgical infrastructure due to more patients seeking colonoscopies secondary to the positive fecal screening intervention resulted in increased wait times and, as a result, decreased compliance. This is an important reminder that despite potential benefits of earlier cancer screening, non-surgical techniques that require diagnostic and/or surgical follow-up do not necessarily overcome barriers to surgical access, may overburden under-equipped systems, and, therefore, should be implemented thoughtfully in low-resource settings.

Lack of economic analyses

Although desperately important, detailed economic and cost-effectiveness studies of cancer surgery performed in low-resource settings are limited ^{13, 57}. A select few of the aforementioned feasibility studies included detailed cost-effectiveness analyses in their evaluation of specific intervention effectiveness and sustainability ^{22, 25}, and others have asserted the importance of considering cost when developing interventions ^{23, 37, 39, 40}. Horton & Gauvreau (2015) produced the most detailed global summaries by surgical oncology subspecialty, even stratifying different interventions by relative cost-effectiveness ⁵⁷. The net return on investing in cancer surgery in terms of patient outcomes is generally viewed as positive. For example, an essential cancer control intervention package for low- and middle-income countries outlined how a USD$20 billion-per-year increase in spending on relevant interventions should ultimately improve cancer outcomes in low- and middle-income countries, which included provision of cancer surgery ⁵⁸. However, detailing the monetary investment return – and comparing this return to the relative cost-effectiveness of alternative interventions – will be important for garnering funding and influencing long-lasting policy change, thus elevating cost-effectiveness as an important area for further research. A holistic cost-effectiveness evaluation should compare cancer surgery to other major health interventions or programs competing for political or philanthropic support, such as infectious disease (i.e. malaria). A critical foundational component of economic and financial planning lies in evaluating the local feasibility of the proposed surgical intervention ^{23, 39, 40}.

As highlighted in Sullivan et al. (2015), the effects of including cancer surgery in universal health care coverage plans in low-resource settings should be evaluated by further research ⁷. Given that cancer surgery is often not explicitly included in universal health care coverage plans, little data exist on the impact, limitations, and costs of increasing access to cancer surgery in settings experiencing significant resource restrictions in their medical systems. In the United States, a decidedly high-resource setting, states that expanded Medicaid coverage under the Affordable Care Act demonstrated a significant increase in cancer surgery utilization among low-income residents ⁵⁹, though further research is needed to determine the ultimate impact on outcomes. It is uncertain whether LMICs will demonstrate a similar effect on service utilization due to differences in resources and settings.

Opportunities

Diverse cancer management strategies and priorities at the local level

An important theme among approaches to strengthening surgical systems is local context and adaptation. It is critical to understand, respect, and center local perspectives toward cancer management strategies and execution when developing interventions or quality improvement strategies ^{38, 60}. A survey conducted among North African physicians across multiple institutions regarding peritoneal surface malignancy management illustrated great diversity in oncologic management strategies ³⁸. This diversity illustrates not only local intervention targets but also opportunities that could potentially be applied to multiple settings, such as developing formal referral structures within local healthcare systems. In this way, “local adaptation” does not necessarily require developing novel interventions but rather requires selecting interventions that respect local context and needs. Another example of this lies in locally validating metrics used in other, perhaps higher-resource settings. For example, a study in Mexico City among patients who underwent surgery for colorectal cancer evaluated patient outcomes using modified Cancer Care Ontario quality-of-care indicators for colorectal cancer management, a framework of indicators designed to compare outcome metrics over time ⁶¹. This study found these indicators, which were produced for primary use in a high-income setting, useful for evaluating improvement over time in their low-resource healthcare setting. While there are certainly benefits to widely standardizing cancer surgery approaches, local adaptation is critical – and feasible ^62–64.

Inter-setting collaboration: research, education, and surgical training

Multiple cancer surgery studies have encouraged bidirectional, thoughtful collaboration between high- and low-income medical centers and surgical providers to mutually share and engage with cancer surgery research, education, and training ^{30, 42, 65–67}. A few studies facilitated explicit, guided opportunities for local stakeholders to produce and execute research proposals to maximize intervention appropriateness. For example, local workshops held by the International Collaboration for Research Methods Development in Oncology (CReDO), demonstrated a high rate of subsequent research project execution among individuals attending from low-resource settings ⁶⁸. Training cancer surgeons in low-resource settings is another topic of international interest, as such operations require a complicated skillset to perform. One study investigating the significance of a training program for Angolan surgeons in Brazil (an upper-middle income country) by the Cooperation Program for Foreign Doctors saw increased surgical specialty diversity in Angola following training ⁶⁹.

Importantly, an ethical partnership and positive relationship must be maintained between partners of lower and higher-resource countries that proactively address sustainability, cultural differences, and overall expectations; Debas et al. (2020) provides an example of guiding principles to ensure these concepts are addressed in partnerships written by the American Surgical Association Working Group for Global Surgery ⁶⁵.

Thoughtful research expansion

Building capacity within low-resource settings to conduct high-quality primary research is of utmost importance in achieving equity in oncology research. This literature search demonstrated an increase in the volume of published global cancer research in low-resource settings since 2015 (Figure 1). In these efforts to expand research in surgical oncology and related topics, it is critical to empower groups who are historically underrepresented in such research, including women and authors from low resource settings ⁷⁰.

Threats

The COVID-19 pandemic

The impact of the COVID-19 pandemic on healthcare systems globally illustrates how external stressors can overwhelm overburdened medical and surgical systems in both low and high resource settings. Few studies have yet to demonstrate the impact of the COVID-19 pandemic on surgical operations in low-resource settings, much less on cancer surgery specifically ^{14, 71–73}. A study conducted in Pakistan showed that breast cancer patients who underwent surgery further into the COVID-19 pandemic presented with more advanced disease that often necessitated more aggressive treatment, perhaps due to fear of contracting COVID-19 and reduced operational capacity during this time ⁷³.

Unchecked technological advancements risk widening disparities

We must encourage explicit consideration of implementation nuances in low-resource settings when evaluating new technological advancements developed in (and for) higher-resource settings. Local context is important to intervention adoption, preparation, delivery, and scaling ⁷⁴. Therefore, as resource-intensive research in high-resource contexts produces new resource-demanding technology, universal implementation of such products may be challenging and therefore could contribute to widening outcome and surgical procedural gaps ⁶⁶.

For example, implementing robotic surgery platforms incurs both hefty up-front and maintenance costs. While locally manufacturing certain components of these expensive systems may eventually help decrease costs, limited data on long-term costs and feasibility call into question the sustainability of modern-day robotic surgery in low-resource areas ⁷⁵. Image-guided surgery for tumor ablation is another increasingly common yet highly resource-intensive surgical approach to cancer ⁷⁶. With advancements in this field developed in high-resource settings leading to increasing technology reliance, such as with the MRI-dependent Minimally INvasive IMage-guided Ablation (MINIMA) technique ⁷⁷, the gap to implementing new standard-of-care approaches grows.

Aforementioned studies investigating local adaptability of technologies widely used in well-resourced areas demonstrate hopeful results. However, when research into surgical technology advancements is conducted, the process of equitable dissemination should be considered at the forefront of the design phase such that downstream project decision-making is rooted in inclusivity.

Discussion

Based on our literature search, there has been a significant increase in the number of published global cancer surgery studies in LMICs since 2015 (Figure 1). This result may indicate increased awareness and research capacity of LMIC stakeholders regarding cancer surgery. There is significant heterogeneity in the topics within cancer surgery in LMICs, perhaps attributable to variability in prioritization, stakeholders, and settings across and within countries. Further, this search only included published works, which may not reflect the direction or outcomes of ongoing, unpublished works at this time. While developing policies more broadly generalizable to LMIC settings may have utility in increasing awareness, collaboration, and perhaps outcomes, the authors surmise that given the diversity, ultimately local stakeholders in their respective LMICs are critical to developing effective local policies and interventions as the stewards of cancer surgery within their specific health ecosystem. Thus, stakeholders and settings may utilize the themes gathered in this review and SWOT analysis to inform local strategies for improving global cancer surgery.

In the 2015 Lancet Commission on Global Cancer Surgery, the authors analyze and describe cancer surgery data across various spheres essential to cancer surgery, including research, surgical systems strengthening, economics and financing, and political framing ⁷. This presents a useful framework for understanding the current landscape of global cancer surgery since this landmark publication, as understood from our literature review.

In terms of research, the current literature suggests a growing emphasis on local disease etiology and pathophysiology, as well as local feasibility studies trialing cancer surgery equipment, approaches, techniques, and technology in local low-resource settings. The definition of “patient outcomes” has itself been challenged to highlight patient quality of life, a qualitative shift that may better reflect local perception of and patient experiences with cancer surgery outcomes. Successful workshops held between participants from low- and high-resource settings to further research and training is encouraging and should remain a focus of research for further development of these collaborations. Engagement of local stakeholders across all levels of research and intervention implementation is critical to success.

To foster further progress in research and global cancer surgery outcomes, there are a few notable opportunities for investigation and expansion. For example, investigators should further characterize the gap in both cancer surgery access and outcomes. Given the heterogeneous nature of the “cancer surgery” field, it is no surprise that the associated risks, complexity, utility, and urgency of different operations vary. There is a need for a more detailed investigation into how these indicators of quality cancer surgery differ by the goal of the cancer surgery performed as this may better highlight targets for intervention.

Further, effective development and local adaptation of surgical techniques, technology, and other quality improvement interventions in low-resource settings relies on high quality feasibility studies. Importantly, feasibility study outcomes are in many ways dictated by local context and thus should be designed and analyzed accordingly; this offers important data about local context. However, larger and more inclusive studies may help identify more generalizable principles for cancer surgery interventions.

Limited cancer surgery infrastructure remains a significant barrier to progress. Postoperative infrastructure, outcomes and complications remain disproportionately poor among patients receiving care in low-resource settings. Moreover, the burden of cancer is growing at a disproportionately high rate in low-resource settings, further stressing limited cancer surgery infrastructure with increased cases and potentially more severe disease. Advancements in technology, while encouraging, also raise the threat of disproportionate distribution. Surgical training in collaboration with higher-resource settings is a promising approach to surgical access expansion when conducted in an ethical, attentive manner. Point-of-care interventions for screening, while effective, may further stress already limited cancer surgery infrastructure in low-resource settings. The COVID-19 pandemic highlighted how other burdens on healthcare may further exacerbate this burden and can contribute to delayed presentation for care. Future research should further investigate ways to optimize cancer surgery coverage and utilization in low-resource settings with less robust healthcare infrastructure such that available surgical systems are adequately prepared for an anticipated increase in utilization.

The economics and financing of surgical oncology in low-resource settings remains an underexplored yet essential component of global cancer surgery efforts. This gap presents a barrier to progress, as limited financial resources in LMICs present challenges to equitable and long-term care provision that must be factored into intervention selection and planning. The local emphasis on research in current literature, as previously described, lays a strong foundation for future financial modeling at a local level, which is critical for informing intervention selection and future funding targets to produce the most efficient, effective outcomes with a given budget. Future feasibility studies should include financial models, when possible, as cost-effectiveness is paramount when defining what interventions may be considered “feasible” in resource-restricted settings.

Finally, the present literature review revealed a paucity of themes pertaining to political framing of global cancer surgery in low resource settings ⁷². Perhaps the most salient point lies in the opportunity for including cancer surgery in universal healthcare coverage, which carries political weight. Further, understanding the relative cost effectiveness of cancer surgery versus other interventions for infectious or other diseases may help inform political or even philanthropic decision-making. This exemplifies how economics and financing of global surgery are intertwined with the political infrastructures governing surgical care delivery. Thus, engaging political figures is important for progress in global cancer surgery.

Conclusion

Global cancer surgery is a growing field. This SWOT analysis describes the landscape of global cancer surgery through a literature review of published studies since the 2015 Lancet Commission. Ultimately, the growing body of published literature in global cancer surgery appears to reflect increased attention to this important area. Of the literature reviewed in this analysis, Strengths include local studies investigating cancer epidemiology as well as surgical and technological innovation, studies that highlight quality-of-life as a key surgical outcome metric, and demonstration of successful interdisciplinary work to promote progress in cancer surgery. Weaknesses include systems-level limitations, such as resource, perioperative services, and broader health system gaps, and a paucity of detailed economic analyses related to cancer surgery. Opportunities include diverse cancer management strategies at the local level, successful inter-setting collaborations to progress research, education, and surgical skills training, and thoughtful research expansion for an inclusive future. Threats include future large-scale stresses on the local healthcare infrastructure like the COVID-19 pandemic and the risk posed by unchecked technological advancements to widening disparities.

This SWOT analysis may inform local intervention strategies and action plans to help stakeholders in LMICs achieve Global Cancer Surgery goals. Similar analyses are needed at the local level help elucidate best practices around the world that might be applied to other similar settings.