Cancer surgical outcome study in Ethiopia: A 7-day multicenter prospective observational cohort study

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Abstract
Background
Safe surgery is a fundamental quality indicator within the global surgery framework. Postoperative complications remain a leading global cause of disability, mortality, and economic loss, with a disproportionate impact on low- and middle-income countries (LMICs).
Objective
This study aims to generate robust epidemiological data on postoperative outcomes of cancer surgery in Ethiopia.
Methods
This study employed a 7-day national observational prospective cohort design. The study enrolled adult patients aged 18 years and older who underwent either elective or non-elective cancer surgery in hospitals across Ethiopia. Statistical analysis included descriptive statistics, chi-square tests for categorical variables, and logistic regression models to identify risk factors for postoperative complications. Outcome measures 7th day postoperative mortality and complications. Statistical significance was set at p < 0.05.
Results
A total of 265 cancer surgeries were performed across 46 hospitals (overall surgeries = 4412). The mean patient age was 46.6 years (SD = 14.9). The majority of patients were classified as low-risk America Society of Anesthesiologists (ASA) physical status classification: ASA I (106/265, 40%) and ASA II (133/265, 50.2%) and low Eastern Cooperative Oncology Group (ECOG) performance status: ECOG 0 (112/265, 42.3%) and ECOG 1 (98/265, 37%). Colorectal cancer surgery was the most common type (38/265, 14.5%), while laparoscopic surgery was performed in only 3/265 cases (1.1%). Postoperative complications developed in 84 of 265 patients (31.7%) with leading complication was superficial surgical site infection 47/265(17.8%). Emergency surgery (AOR = 3.1, 95% CI: 1.1–8.4, p = 0.003), comorbidity (AOR = 2.0, 95% CI: 1.1–3.7, p = 0.025), and an ECOG performance status of III (AOR = 9.5, 95% CI: 1.5–61.1, p = 0.02) were statistically significantly associated with 7th day postoperative complications. The overall 7-day mortality rate after cancer surgery was 5/265 (1.9%).
Conclusion
Despite the relatively young age of patients, their low ASA physical status scores, and good ECOG performance, a significant proportion experienced adverse outcomes following cancer surgery: one in three patients developed postoperative complications, one in nine required reoperations, and one in 53 died. These findings suggest a critical need for evidence-based interventions to strengthen the underlying infrastructure and care processes within the surgical system which are essential to achieving safe, effective, and high-quality surgical care for cancer patients in Ethiopia.
Citation: Awedew AF, Tsegaye YA, Ayen AA, Tesifaw FG, Amsalu BT, Getahun AM (2026) Cancer surgical outcome study in Ethiopia: A 7-day multicenter prospective observational cohort study. PLoS One 21(7): e0354980. https://doi.org/10.1371/journal.pone.0354980
Editor: Abraham Tamirat Gizaw, Jimma University College of Public Health and Medical Sciences, ETHIOPIA
Received: March 14, 2026; Accepted: July 15, 2026; Published: July 29, 2026
Copyright: © 2026 Awedew et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The dataset used and/or analyzed data (Cancer outcome in Ethiopia.xlsx) during the current study is provided as a supplementary file.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ASOS, African Surgical Outcomes Study; AOR, Adjusted Odd Ratio; ASA, American Society of Anesthesiologists; ECOG, Eastern Cooperative Oncology Group; HICs, High, income countries; ISOS, International Surgical outcome study; LMICs, Low, and middle, income countries (LMICs); POMR, Perioperative mortality rate (POMR); SaLTS, Saving Lives through Safe Surgery; SD, Standardized deviation; SPSS, Statistical Package for the Social Sciences; UHC, Universal health coverage; VIF, Variance inflation factor; WHO, World Health Organization
Introduction
Cancer remains a substantial global health challenge, contributing significantly to mortality, morbidity, and disability worldwide [1–3]. Cancer ranks as the second leading cause of global deaths and disability worldwide, with the burden falling disproportionately on low- and middle-income countries (LMICs), including Ethiopia, whose healthcare systems often face considerable resource constraints [1–3].
Surgical health care plays a crucial role across the cancer continuum, encompassing prevention, control, diagnosis, treatment, and rehabilitation [4]. Access to safe, affordable, and equitable surgical services integrate to achieve universal health coverage, Sustainable Development Goals and national cancer control plans [5]. Cancer surgery performs for a wide array of purposes, including curative, palliative, diagnosis, and reconstruction interventions [6]. Approximately 80% of all cancers necessitate some form of surgical management [6], resulting in estimated global need for 32 million cancer-related operations annually as of 2015, a figure projected to increase to 45 million by 2030, emphasizing the escalating demand for surgical services in cancer care [6]. Furthermore, the most recent modeling data from 2021 projects a substantial 52% increase in global surgical cancer cases between 2018 and 2040 [7]. This projection indicates an approximate need for an additional 5 million procedures for cancer-related indications in 2040 compared to 2018, highlighting the urgency of expanding surgical capacity and resources [7].
Providing quality cancer surgery is a complex undertaking requiring substantial human, financial, and technological resources [6]. This often necessitates access to advanced imaging, pathology services, and adjunct oncologic therapies, such as chemotherapy, radiotherapy, and immunotherapy [8]. Due to the significant resource demands, access to quality cancer surgery is markedly disparate: less than 5% of low- and middle-income countries (LMICs) are able to provide adequate, affordable, equitable, and safe cancer surgical care, while more than 95% of high-income countries (HICs) offer readily available access to such services [8]. This stark disparity highlights the profound inequalities in global cancer care [8].
Surgical care has historically been neglected within national public health agendas in Ethiopia, a common challenge across many low- and middle-income countries (LMICs) [9]. The Lancet Commission on Global Surgery has, however, spurred a positive shift in awareness and policy focus, including in Ethiopia. The country developed a national surgical policy, known as “Saving Lives through Safe Surgery” (SaLTS), in 2015 [10], which primarily aimed to institutional capacity building which able to perform basic essential surgery, surgical workforce development and Task-shifting/Task sharing modeling to achieve safe and equitable surgical care. Despite these positive developments, the policy framework has yet to adequately address the specific challenges of cancer surgery, resulting in significant gaps in surgical outcomes for cancer patients in Ethiopia. Therefore, this study aims to address the evidence gap on cancer surgical outcomes in Ethiopia, generating actionable data to inform evidence-based policy, advance cancer surgical research, and providing essential insights for policymakers, researchers, and healthcare professionals.
Methodology
Study design
We conducted a national, prospective, observational cohort study across 46 hospitals in all regions of the country. Each participating hospital selected one month from January to April 2024 as their data collection period. During this month, all consecutive patients admitted for elective or non-elective inpatient cancer surgery -with a planned overnight stay -were enrolled. Each enrolled patient was then followed for 7 days after their surgery to monitor postoperative outcomes. Patients undergoing planned day cancer surgery, pediatrics (age < 18 years), or radiological procedures not requiring anaesthesia were excluded.
Data collection
The data collection tool was designed based on previous international surgical outcome studies. It captured key variables across the preoperative, intraoperative, and postoperative phases of surgical care. Data were collected using well-validated data collection tool used for the Africa Surgical Outcome Study (ASOS) [11] and International Surgical Outcome Study (ISOS) [12]. The outcome measure included 7th day in-hospital mortality, post-operative complication and prevalence of critical illness. The data were collected by surgeons, medical interns, residents, and anesthetists. Detailed tracking of complications severity, such as infectious complication, cardiovascular complication, and other complications were assessed. Data collection tools provided at Supplement file 1.
Data analysis
All collected data underwent supervisor review and systematic validation. A designated supervisor examined each completed questionnaire for accuracy, consistency, and completeness, cross-referencing assigned participant codes throughout the process. Any discrepancies or missing entries were resolved through re-verification with the original data source prior to entry into the study database. Data analysis was performed using SPSS software, version 25. Categorical variables were summarized using frequencies and percentages, and comparisons between groups were conducted using the chi-square test. The normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data were described using means and standard deviations, while skewed data were characterized using medians and interquartile ranges. Prior to multivariable analysis, a multicollinearity test was performed to evaluate potential correlations between categorical, continuous, and binary variables. Multicollinearity was assessed using the variance inflation factor (VIF) and tolerance values. Variables exhibiting a VIF below 5 and a tolerance above 0.1 were considered sufficiently independent and were subsequently included in the multivariable binary logistic regression analysis. Conversely, variables with a VIF score ranging from 5 to 10 or higher, and a tolerance value below 0.1, were excluded from the final model to avoid issues arising from multicollinearity. To identify potential predictors, a univariate binary logistic regression analysis was initially performed to examine factors associated 7th day postoperative complications. Variables demonstrating a p-value of 0.2 or less in the bivariate analysis were then entered into a multivariable binary logistic regression model. This model was used to assess the independent associations between the various factors and the outcomes of 7th -day postoperative complications. The results of the logistic regression analysis are reported as adjusted odds ratios (OR) with corresponding 95% confidence intervals. A p-value less than 0.05 was used as the threshold for statistical significance.
Ethical consideration
Results
A total of 265 cancer surgeries were performed across 46 hospitals (overall surgery = 4412), with a mean patient age of 46.6 years (SD = 14.9) with slight female predominance (154/265, 58.1%). The majority of patients were classified as low risk according to the ASA physical status classification: ASA I (106/265, 40%) and ASA II (133/265, 50.2%). Similarly, most patients had a low ECOG performance status: ECOG 0 (112/265, 42.3%) and ECOG 1 (98/265, 37%). Comorbidities were present in 96 of 265 patients (36·2%). Colorectal cancer surgery (38/265, 14.5%) and breast cancer surgery (27/265, 10.2%) were the most common procedures performed. Most surgeries were elective (160/265, 60.4%) and classified as major (205/265, 77.4%). Underutilization of the WHO Surgical Safety Checklist was observed in 42/265 (15.8%) of cases, and laparoscopic surgery was performed in only 3/265 (1.1%) of cases. Approximately 43/265 (16.2%) of patients required immediate critical care admission (Table 1)
Cancer surgical outcome
Postoperative complications developed in 84 of 265 patients (31.7%). According to the Clavien-Dindo classification, 29 of 265 patients (10.9%) experienced Grade 1 complications, and 30 of 265 patients (11.3%) experienced Grade 2 complications. Grade III or higher postoperative complications, requiring either radiological or open surgical intervention, developed in 29/265 patients (11.1%). The most frequent complications were superficial surgical site infection in 47 of 265 patients (17·8%), deep surgical site infection in 18 of 265 (6·8%), and bloodstream infection in 11 of 265 (4·2%). The overall 7-day postoperative mortality rate was 5 of 265 patients (1·9%). (Table 2 and 3).
Several factors are associated with postoperative complications following cancer surgery. After adjusting for confounders, the following factors were statistically significantly associated with postoperative complications: emergency surgery (AOR = 3.1, 95% CI: 1.1–8.4, p = 0.003), comorbidity (AOR = 2.0, 95% CI: 1.1–3.7, p = 0.025), an ECOG performance status of III (AOR = 9.5, 95% CI: 1.5–61.1, p = 0.02), and age older than 45 years (AOR = 2.2, 95% CI: 1.2–4.1, p = 0.008) (Table 4)
Discussion
This study reveals the substantial burden of cancer surgery in Ethiopia, with approximately one in 17 surgical procedures performed in the nationally attributable to cancer. The leading cancer types requiring operative intervention were colorectal, breast, hepatobiliary and pancreatic, and neurological malignancies. Notably, one in three patients experienced postoperative complications, one in nine required reoperations, and one in 53 died within seven days of cancer surgery.
The postoperative complication rate observed in our study- approximately one in three patients – was three times in the Africa Surgical Outcome Study (ASOS) [11] and the International Surgical Outcome Study [12], which reported the overall complication approximately 18% and 17% respectively [11,12]. This discrepancy is not easily explained by patients baseline sociodemographic and clinical characteristics; our patients were young, low ASA, good ECOG and low comorbidity rate- parameters associated with favorable operative risks. The high complication rate observed in our study implicates systemic and structure factors inherent from the surgical care delivery system, rather that patient level physiology alone. The delay diagnosis, advanced presentation, poor preoperative optimization, neoadjuvant optimization, intraoperative techniques and postoperative monitoring are likely contributors. These findings are consistent with evidence from the GlobalSurg Collaborative, which demonstrated that complication profiles in LMICs are disproportionately shaped by hospital and country-level factors, independent of individual patient risk [13].
The Lancet Commission on Global Surgery identified the perioperative mortality rate (POMR) as a cardinal indicator of surgical system strength [5]. Ethiopian Ministry of Health adopted the lancet recommendations and planning a national target of less than 2% by 2025 [14]. The seven-day POMR of approximately 2% in the present study was broadly consistent with rates reported in the African Surgical Outcomes Study (ASOS: 2.1%) [11] and the International Surgical Outcomes Study (ISOS: 1.5%) [12], nominally meeting the national benchmark However, this figure warrants careful interpretation: our cohort was markedly younger and had substantially lower physiological risk, as reflected by lower ASA and ECOG scores, compared with ASOS, ISOS, and high-income country populations. A 2% POMR in a younger, functionally preserved cohort likely represents a disproportionately higher risk-adjusted mortality than the equivalent rate observed in older, more comorbid populations elsewhere. Meeting the national target should therefore not be equated with optimal surgical safety, and risk-adjusted benchmarking remains essential for driving meaningful quality improvement in Ethiopian cancer surgical centres.
We also found that reoperation rate was approximately one in nine patients, which is higher from previous studies [15]. Unplanned return to operation room is a widely accepted surgical quality indicators, reflecting multiple stage failure during surgery delivery from preoperative decision making to post operative surveillance. Reoperations carry compounded risks: each additional anaesthetic exposure and procedure substantially increases both mortality risk and length of stay, placing additional demands on already-strained theatre capacity, blood bank resources, and intensive care facilities. Reducing avoidable reoperations must therefore be considered a strategic priority for quality improvement programmes in Ethiopian surgical centres.
Evidence from large-scale, multicentre international studies spanning 82 countries demonstrates that adverse postoperative outcomes following cancer surgery arise from a dual burden of patient-specific and health-system determinants [13]. Approximately 60% of postoperative complications are attributable to patient-level factors- including delayed presentation, advanced disease stage, tumour histology, and functional reserve- while the remaining 40% are independently linked to hospital and country-level factors, encompassing diagnostic capability, perioperative care quality, and human resource capacity, as quantified by the Socio-Demographic Index (SDI) [13]. Of particular concern, inconsistent availability of postoperative care facilities in LMICs has been associated with an excess of seven to ten deaths per 100 major complications [13]- a preventable toll that represents a measurable indicator of health system inequity. Investment in high-dependency and intensive care capacity must therefore be recognised as a core, rather than ancillary, component of Ethiopia’s surgical expansion agenda.
The Ethiopian Ministry of Health’s Saving Lives Through Safe Surgery (SaLTS) initiative represents an important national commitment to expanding surgical access and improving operative quality, primarily through the strengthening of essential service delivery capacity, facility infrastructure, and surgical workforce development [16]. Our findings, however, reveal a significant performance gap relative to the SaLTS II 2025 targets- specifically, a surgical site infection rate below 5%, underscoring the distance that remains between policy ambition and clinical reality. Robust and sustained financing of surgical infrastructure and human resource capacity constitutes the foundational prerequisite for delivering safe, equitable, and affordable surgical care, and is integral to achieving universal health coverage (UHC) and the Sustainable Development Goals (SDGs).In this context, Ethiopia’s public health expenditure -which remains below 5% of the national budget and falls substantially short of the 15% benchmark enshrined in the Abuja Declaration -represents a critical structural impediment to surgical system strengthening, a challenge shared by many low- and middle-income countries. Without a substantial and sustained reorientation of public investment toward surgical care, encompassing infrastructure, workforce capacity, essential medicines, and quality improvement systems, progress in surgical oncology will remain geographically inequitable, systemically fragile, and inadequate to address the growing population burden of cancer.
The Lancet Commission on Global Surgery has proposed the safe and equitable surgical cares are a cardinal national indicator for evaluating surgical system strength [5]. Building on this foundation, the Lancet Global Health Commission on High-Quality Health Systems articulated a tripartite framework for achieving safe, affordable, and timely surgical care, comprising essential foundations -encompassing infrastructure, workforce, and financing – robust care processes, including quality assurance, patient safety systems, and health data infrastructure, and demonstrable quality impact as the measurable expression of system performance [17]. Translating this framework into actionable reform within the Ethiopian context demands a coherent and sustained policy response: national cancer surgery planning must be explicitly aligned with universal health coverage (UHC) principles; surgical care must be formally integrated into the essential health benefits package to ensure equitable access across socioeconomic strata; and routine surgical audit, morbidity and mortality review, and structured quality improvement cycles must be institutionalized as standard practice across all levels of the health system. Collectively, these measures represent the minimum programmatic architecture required to close the prevailing gap between surgical policy aspiration and clinical reality, and to deliver safe, equitable, and affordable cancer surgical care to the Ethiopian population.
There are some limitations inherent to this study that warrant careful consideration. The seven-day observational window represents a constrained follow-up period that likely underestimates the true incidence of postoperative mortality and morbidity, given that a substantial proportion of infectious, nutritional, and wound-related complications characteristically manifest beyond this timeframe, thereby potentially obscuring the full burden of adverse surgical outcomes. Furthermore, although the multicenter design enhances generalizability across diverse healthcare settings in Ethiopia, unmeasured institutional variability in infrastructure, surgical technique, perioperative protocols, and postoperative care standards may introduce heterogeneity that limits direct comparability across participating centers. Additionally, as with all observational cohort studies, the possibility of residual confounding from unmeasured clinical, socioeconomic, and pathological variables cannot be entirely excluded, which may influence the magnitude and direction of observed associations. Therefore, future research should address longer-term follow-up extending beyond the immediate seven-day postoperative period to capture late complications and survival outcomes. Additionally, subsequent investigations should also examine hospital-level and health-system-level determinants, including workforce training, infrastructural capacity, and perioperative protocols, that may account for the observed variations in surgical outcomes.
Conclusion: Our findings indicate that postoperative complication rates were significantly higher, nearly three, times compared to those reported in high-income countries. This is particularly concerning given that our patient population was relatively young and had low ASA class and ECOG performance scores, typically indicators of lower risk. These results strongly suggest that incompetent in care processing system and the foundational elements of surgical service delivery in Ethiopia, significantly compromise the quality dimension of surgical care
Supporting information
S2 File. Cancer outcome in Ethiopia.xlsx (analyzed Data).
https://doi.org/10.1371/journal.pone.0354980.s002
(XLSX)
References
- 1. Bray F, Laversanne M, Sung H. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63.
- 2.
Wild CP, Weiderpass E, Stewart BW. World Cancer Report: Cancer Research for Cancer Prevention. Lyon, France: International Agency for Research on Cancer. 2020.
- 3. Bray F, Laversanne M, Weiderpass E, Soerjomataram I. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer. 2021;127(16):3029–30. pmid:34086348
- 4. Romero Y, Trapani D, Johnson S, Tittenbrun Z, Given L, Hohman K, et al. National cancer control plans: a global analysis. Lancet Oncol. 2018;19(10):e546–55. pmid:30268693
- 5. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. pmid:25924834
- 6. Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015;16(11):1193–224. pmid:26427363
- 7. Perera SK, Jacob S, Wilson BE, Ferlay J, Bray F, Sullivan R, 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):182–9. pmid:33485458
- 8. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-23. pmid:25926087
- 9. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533–6. pmid:18311574
- 10. Burssa D, Teshome A, Iverson K, Ahearn O, Ashengo T, Barash D, et al. Safe Surgery for All: Early Lessons from Implementing a National Government-Driven Surgical Plan in Ethiopia. World J Surg. 2017;41(12):3038–45. pmid:29030677
- 11. Biccard BM, Madiba TE, Kluyts H-L, Munlemvo DM, Madzimbamuto FD, Basenero A, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet. 2018;391(10130):1589–98. pmid:29306587
- 12. International Surgical Outcomes Study group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth. 2016;117(5):601–9. pmid:27799174
- 13. GlobalSurg Collaborative Groups. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet. 2021;397(10272):387–97.
- 14. Kifle F, Iverson KR, Belay E. Towards establishing a national perioperative quality improvement network in LMICs: Implementation experiences from Ethiopia. Ann Surg Open. 2024;5(3):e480.
- 15. Merkow RP, Bilimoria KY, Cohen ME, Richards K, Ko CY, Hall BL. Variability in reoperation rates at 182 hospitals: a potential target for quality improvement. J Am Coll Surg. 2009;209(5):557–64. pmid:19854394
- 16.
Ministry of Health, Health Service Quality Directorate (HSQD)(Ethiopia). 2021. National Surgical Care Strategic Plan: Saving Lives Through Safe Surgery II (SaLTS II, 2021–5). Addis Ababa, Ethiopia.
- 17. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196–252. pmid:30196093