Surgical Services for Cancer Care

Surgery is a fundamental modality for curative and palliative treatment of most cancers in countries across all income settings. In high-income countries (HICs), where the most common solid organ malignant cancers, such as breast and colon cancers, are more likely to be successfully diagnosed at early stages, surgical resection provides definitive locoregional control of the primary tumor. This approach has significant curative potential when combined with appropriately selected adjuvant systemic treatment and radiotherapy. In low- and middle-income countries (LMICs), where locally advanced or metastatic cancer is a common initial disease presentation, surgical resection or debulking may be one of the few available modalities to achieve reasonable palliative disease control. Surgery has not received sufficient attention in the cancer control discussion in LMICs (Goss and others 2014; Purushotham, Lewison, and Sullivan 2012). With many competing health priorities and significant financial constraints, surgical services in these settings are given low priority within national health plans and are allocated few resources from domestic accounts or international development assistance programs (Bae, Groen, and Kushner 2011; Farmer and Kim 2008). As a result, in most low-income countries (LICs), and many middle-income countries (MICs), access to safe, optimal surgical services for cancer is poor, and large proportions of the population are unable to access even the most basic surgical care (Funk and others 2010). The projected increase in the cancer burden in LMICs over the next 20 years (see chapter 2 in this volume) necessitates that all countries give consideration to the establishment of surgical services with adequate capacity to meet current and future needs. In general, significant capital investment in surgical infrastructure, equipment, and personnel is needed in LICs, especially those in Sub-Saharan Africa (LeBrun and others 2014). In MICs, improved coordination, regulation, financial risk protection, and strategic planning for cancer and surgical services are requisites to improve service delivery and outcomes (Goss and others 2014). Surgical capacity building takes time, particularly with respect to developing the surgical workforce. Efforts to strengthen surgical services in LMICs should be strategically proactive to facilitate the provision of safe, effective, and accessible surgical cancer care for current and future patients. This chapter discusses the public sector delivery of surgical cancer services in resource-constrained environments. We describe the current status of surgical services for cancer care in LMICs, analyze the barriers to care, and outline the surgical delivery platforms available to countries at different resource and income levels. Key considerations for policy makers relating to quality, safety, access, coverage, and economic and planning considerations in the scale-up of surgical cancer services are highlighted.