Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis.

Emma R Allanson,Yee Leung,Aime Powell,Lynette Denny,Max Bulsara,Paul Cohen,Hong Lim Lee,Sudeep Gupta

doi:10.1371/journal.pone.0217775

Abstract

ObjectiveTo investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC).MethodsThe Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS).FindingsData were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19–0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00–0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01–0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01–0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01–0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01–0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01–0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00–0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04–0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy.ConclusionThis is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.

Highlights

Cervical cancer is the third most common malignancy in women worldwide and performs poorly in all objective measurements of outcomes in less developed countries[1]
I2 95.72, P = 0.00). 5-year Progression free survival (PFS) was 83% for laparotomy, 84% for laparoscopy and overall survival (OS) was 85% for laparotomy cases and 80% for laparoscopy. This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in low and middle-income countries (LMIC), which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation
This is relevant in LMIC, where surgeons may be the sole physician involved in delivery of cancer care[3]

Summary

Introduction

Cervical cancer is the third most common malignancy in women worldwide and performs poorly in all objective measurements of outcomes in less developed countries[1]. The disease is a notable example of an extreme global health disparity with almost all cervical cancers, and the deaths caused by them, occurring in low and middle-income countries (LMIC)[2]. Contributors to this inequity are complex and multifaceted and include insufficient access to HPV vaccines and screening, and lack of trained health care professionals, radiation services and infrastructure, that prohibit reductions in cervical cancer incidence and mortality within these countries [3]. Surgical care should be a fundamental component of all health systems regardless of development level This is relevant in LMIC, where surgeons may be the sole physician involved in delivery of cancer care[3].

Methods

Results

Conclusion