In certain regions of the world, cancer claims more lives than HIV, tuberculosis, and malaria combined, yet surgery has been relegated to the sidelines of global health initiatives. This critical need to address global inequities in access to safe, timely, and affordable cancer surgery led to the creation of the Lancet Oncology Commission on Global Cancer Surgery.
The first Commission report, published in 2015, highlighted the global burden of cancer and the importance of cancer surgery while documenting disparities worldwide.1 A second Commission report published in 2023 focuses on pragmatic solutions and actionable recommendations to improve surgical cancer care for every patient, regardless of socioeconomic status or geographic location.2
Chandrakanth Are, MBBS, MBA, FRCS, FACS
The ASCO Post spoke with Lead Commissioner of the second report, Chandrakanth Are, MBBS, MBA, FRCS, FACS. Dr. Are is the Jerald L. and Carolynn J. Varner Professor of Surgical Oncology and Global Health, Associate Dean of Graduate Medical Education, and Vice Chair of Education at the University of Nebraska Medical Center, Omaha. He presented the major findings of the report and the Commission’s recommendations for further action.
Role of Surgery in Cancer Care
“The significance of surgery and surgeons in cancer care is often overlooked by policymakers, public health communities, and even within the medical field itself,” Dr. Are said, adding that “surgery has been the ‘neglected stepchild’ of global health.” He emphasized that surgeons should be present at oncology leadership meetings and policy discussions to help ensure that surgery is an essential part of cancer control plans and resource allocation decisions.
The cancer surgical landscape has changed over the last 8 years, and Dr. Are explained that “although surgical oncology may still be marginalized in some areas, including visibility, importance, advocacy, and funding, the role of surgery in cancer care is less of an afterthought now.” Even so, he added, “further progress is needed.”
Lancet Oncology Commission on Global Cancer Surgery
- Chandrakanth Are, MBBS. MBA, FRCS, FACS
- Shilpa S. Murthy, MD, MPH
- Richard Sullivan, MD
- Makayla Schissel, MPH
- Sanjib Chowdhury, PhD
- Olesegun Alatise, MD
- Daniel Anaya, MD
- Madhuri Are, MD
- Charles Balch, MD
- David Bartlett, MD
- Murray Brennan, MD
- Lydia Cairncross, MMED
- Matthew Clark, MD
- S.V.S. Deo, FACS
- Vikas Dudeja, MBBS
- Domenico D'Ugo, MD
- Ibtihal Fadhil, PhD
- Armando Giuliano, MD
- Satish Gopal, MD
- Lily Gutnik, MD
- Andre Ilbawi, MD
- Pankaj Jani, FRCS
- Peter Kingham, MD
- Laura Lorenzon, MD, PhD
- Premila Leiphrakpam, PhD
- Augusto Leon, MD
- Hector Martinez-Said, MD, MPP
- Kelly McMasters, MD, PhD
- David O. Meltzer, MD
- Miriam Mutebi, MMed, MSc
- Syed Nabeel Zafar, MBBS
- Vibhavari Naik, MD
- Lisa Newman, MD, MPH
- Alexandre Ferreira Oliveira, MD, PhD
- Do Joong Park, MD, PhD
- C.S. Pramesh, MS
- Saieesh Rao, MD
- Subramanyeshwar Rao, MCh
- Enrique Bargallo-Rocha, MD
- Anya Romanoff, MD
- Anne F. Rositch, PhD
- Isabel T. Rubio, MD, PhD
- Heber Salvador de Castro Ribeiro, MD, PhD
- Eman Sbaity, MD, MSc
- Maheswari Senthil, MD, MSc
- Lynette Smith, PhD
- Masakazi Toi, MD, PhD
- Kiran Turaga, MD, MPH
- Ujwal Yanala, MBBS
- Cheng-Har Yip, FRCS
- Ashraf Zaghloul, MD, PhD
- Benjamin O Anderson, MD, FACS
Dr. Are said that part of the challenge is that cancer leadership on the global stage is conspicuous by its absence. “The first commission shed some light, and that has helped, but not to the extent we want. It was felt that the time was ripe for another commission to continue that effort of improving access to cancer surgery not only globally, but closer to home as well.”
In framing the Second Commission on Global Cancer Surgery, Dr. Are explained, “We included about 50 cancer surgery experts and leaders from across the world offering diverse perspectives, and we came up with a roadmap of pragmatic, simple and reality-grounded solutions and actions. These solutions and actions may not be moonshots, but they are ‘groundshots’ that are realistic and can apply to every part of the world.
Improving Access to Cancer Surgery
Many patients with various ailments, including obstetrics, trauma, and cardiac disease, will need surgical intervention at some point. For patients with cancer, the percentage is significantly higher. “Data from the first Commission report showed that a staggering 80% of patients with solid tumors require surgical intervention at least once during their cancer care, with some needing multiple surgeries. Unfortunately, only 25% of patients with cancer worldwide had access to safe, affordable, and timely surgery.”
“Surgical infrastructure is heavy, and most places tend to focus on short-term investments rather than the long-term benefits that can be realized through amortization across specialties,” said Dr. Are, theorizing possible reasons for this neglect. “Secondly, in regions where surgical intervention is needed the most, 70% to 80% of cancers present at a late stage, rendering surgery ineffective except for palliation. Finally, at an individual level, surgery is expensive—although not as expensive as some of the other treatment modalities,” he said.
By drawing upon the expertise from approximately 50 cancer surgery leaders from around the world (see sidebar), the second Commission report was built on the foundation laid by the first. Dr. Are, underscored the second Commission’s focus on pragmatic, contextually relevant solutions to improving access to cancer surgery.
“Instead of looking forward to the next technological or systemic therapy miracle, let’s look at what we already have now and see how we can implement that better,” said Dr. Are. “Solutions to address this grave humanitarian imbalance need not always be astronomical in thought or cost. [Our intent] was to develop a roadmap of practical solutions that are grounded in reality and published in a modular format so that they can be taken out one at a time depending on the geographic region.”
The report is divided into three main sections:
- Section 1. Global solutions to improve surgical care within nine domains of cancer surgery. These domains were chosen on the basis of (a) areas that need improvement; (b) those that are most likely to make a substantial difference; and (c) those that have the potential to cover as much of the direct cancer surgical care pathway as possible.
- Section 2. Region-specific solutions based on the six World Health Organization (WHO) regions to improve surgical care within all nine domains. Examples of existing regional initiatives that have either worked well or need further support are also summarized.
- Section 3. A call to action, based on the solutions outlined in sections 1 and 2, this section outlines eight broad actions to propel essential improvements in the global capacity for cancer surgery.
Nine domains of cancer surgery are identified in section 1. According to Dr. Are, these domains were chosen based on areas that needed the most improvement, the likelihood of making a substantial difference, and the potential to cover as much of the direct cancer surgical care pathway as possible. He noted “These nine domains were refined to identify solutions specific to the six WHO regions, namely Africa, the Americas, Eastern Mediterranean, Europe, Southeast Asia, and Western Pacific.”
Dr. Are outlined the nine domains as follows:
- Emphasizing the role of surgery and surgeons in cancer care
- Basic requirements for establishing or expanding cancer surgery services
- Incorporation of technology in cancer surgery
- Other specialties integral to providing optimal cancer surgical care
- Patient safety and quality improvement in cancer surgery
- Enhancing the role of research in cancer surgery
- Education of surgical workforce pertaining to cancer surgery
- Economic effect of providing safe, timely, high-quality, and value-based cancer surgery
- Scaling up the cancer surgical workforce.
Region-Specific Solutions and Action Items
In section 2, the Commission provides region-specific solutions for each of the six WHO regions to ensure that the proposed solutions are geographically and contextually relevant. Cancer surgery leaders from each region provided input specific to the nine domains, highlighting commonalities, region-specific contexts, challenges, and solutions. Finally, in section 3, a comprehensive set of eight action items are outlined (see sidebar).
Dr. Are explained, “These measures serve as a call to action for policymakers, health-care professionals, and other stakeholders to facilitate essential improvements in global access to safe, timely, and affordable cancer surgery. These action items are designed to be broad in scope, nonbinding, and applicable to as many regions of the world as possible.”
Dr. Are also emphasized the importance of applying implementation science principles to increase the likelihood of effective application of these solutions.
“As we know, most new ideas die during implementation,” said Dr. Are. “That’s why we used the Consolidated Framework for Implementation Research to assess potential barriers and facilitators to these new health-care initiatives.”
Although it is still early to gauge the full impact of the Lancet Oncology Commission report on global cancer surgery, there are already real-world examples of how it is making a difference. As the Chief Executive Officer of the Global Forum of Cancer Surgeons, which includes cancer surgery leaders from around 80% of the world, Dr. Are shared an instance where the Commission’s findings were used to support policy changes.
Real-World Example of Impact
In Brazil, cancer care providers were struggling to secure reimbursement for cytoreductive surgery, a procedure that involves the surgical removal of tumors combined with hyperthermic intraperitoneal chemotherapy. The Brazilian surgical community reached out to Dr. Are and the Global Forum of Cancer Surgeons for support. In response, they drafted a letter advocating for reimbursement, which, along with efforts from other stakeholders, successfully lobbied the Brazilian government to approve reimbursement of $14,000 per patient for this procedure.
“This example shows how the tools and evidence provided by the Commission can be used to drive policy changes and improve access to cancer surgical care in real-world settings,” said Dr. Are, who continues to promote the findings and recommendations of the Commission around the world.
Action Items Identified in the Lancet Oncology Commission on Global Cancer Surgery
- Action 1: Ensure that all patients can access cancer surgery across all six phases of cancer care, from prevention to end-of-life care. This includes initiatives such as ensuring availability, accessibility, timeliness, safety, and affordability of surgical care, as well as addressing inequities based on race, gender, ethnicity, sexual orientation, and nationality.
- Action 2: Increase the availability and development of contextually appropriate educational platforms for training future cancer surgeons. This involves incorporating oncology principles in medical school curricula, increasing cancer surgery components in early surgical training, and standardizing educational curricula to include essential technical and nontechnical skills.
- Action 3: Develop geographically relevant, resource-stratified research platforms that promote cancer surgical research. This includes raising awareness about the importance of research, improving research capacity, developing regulatory bodies, and promoting collaborations to address inequities in cancer research output.
- Action 4: Create and increase the capacity for a skilled cancer surgical workforce that provides quality care within a multidisciplinary team. This involves initiating financing policies, developing equitable labor market and educational policies, standardizing cancer operations and workforce distribution, and promoting interprofessional collaborations.
- Action 5: Incorporate patient safety and quality improvement principles into every aspect of surgical care. This includes promoting awareness, incorporating education, increasing knowledge of safety principles and tools, and creating cohesive teams that prioritize patient safety.
- Action 6: Provide continuing medical education and ongoing professional development for surgeons to ensure competence aligned with current evidence-based practices. This involves improving awareness of current principles, providing information channels for new technologies and practices, and creating ongoing learning pathways.
- Action 7: Promote well-being among surgeons and the cancer care workforce through initiatives such as destigmatizing mental health, promoting supportive organizational cultures, creating mentorship programs, and developing policies that address workplace-related issues.
- Action 8: Create resilient cancer surgical care delivery platforms to ensure safe and timely cancer surgery during global catastrophic events. This involves making information available, investing in resilient infrastructure, supporting multisectoral collaborations, promoting global cooperation, and developing partnerships to provide clinical expertise.
Closing Thoughts
Although the ethical imperative for action is made throughout the Commission’s report, Dr. Are said that the economic case for investment in cancer surgery is also made, noting that “exclusive of other surgical treatments, provision of cancer surgery alone would avert $12.1 trillion in direct economic losses worldwide from 2015 to 2030.”
In the Commission’s second report, the committee noted that “Surgery is not only one of the most cost-effective methods of treatment, but also tends to be more durable for many malignancies. Unfortunately, for most patients, particularly for those in low- to middle-income countries, restricted access to safe, timely, high-quality, and affordable cancer surgical care is a harsh reality.”
Dr. Are furthered this, saying that “Everything in this [report] is aspirational, but with the hope of attainment sometime in the future,” he said. “Access to effective cancer surgery should not be a privilege for a few, but a societal necessity for all.”
Dr. Are concluded, saying: “We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location. We hope this Commission offers the practical guidance necessary to overcome these challenges.”
Editor’s note: Dr. Are is presenting the eight-point action plan to propel improvements in access to cancer surgery at the World Cancer Congress on September 18 in Geneva. Organized by The Society of Surgical Oncology: Global Forum of Cancer Surgeons, this session is titled “Promoting equity, quality and value in global cancer care,” will be chaired by John Varallo, MD, of the Global Surgery Foundation (United States). To learn more, visit WorldCancerCongress.org.
The Lancet Commission Report on Global Cancer Surgery was initially unveiled on November 2, 2023, at the 3rd Indian Cancer Congress, held in Mumbai, India, a joint meeting of the four major oncology societies in India: Indian Association of Surgical Oncology, Indian Society of Medical and Pediatric Oncology, Indian Society of Oncology, and Association of Radiation Oncologists of India. The commission was also launched via a Lancet webinar at the 2023 London Global Cancer Week on November 14, 2023, and at the 2024 Annual Meeting of the Society of Surgical Oncology, held in Atlanta.
DISCLOSURE: Dr. Are holds a patent for a laparoscopic instrument with the University of Nebraska and serves in leadership positions and on committees for the Society of Surgical Oncology, American College of Surgeons, Indian Association of Surgical Oncology, The Global Forum of Cancer Surgeons, Basavatarakam Indo-American Cancer Hospital and Research Institute, National Cancer Institute, National Comprehensive Cancer Network, and Accreditation Council for Graduate Medical Education.
REFERENCES
1. Sullivan R, Alatise OI, Anderson BO, et al: Global cancer surgery: Delivering safe, affordable, and timely cancer surgery. Lancet Oncol 16:1193-1224, 2015.
2. Are C, Murthy SS, Sullivan R, et al: Global Cancer Surgery: Pragmatic solutions to improve cancer surgery outcomes worldwide. Lancet Oncol 24:e472-e518, 2023.
