title: The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries.
abstract: BACKGROUND
  Cancer continues to rise as a contributor to premature death in the developing world. Despite this, little is known about whether cancer outcomes are related to a country's income level, and what aspects of national healthcare systems are associated with improved cancer outcomes.
  
  
  METHODS
  The most recent estimates of cancer incidence and mortality were used to calculate mortality-to-incidence ratio (MIR) for the 85 countries with reliable data. Countries were categorized according to high-income (Gross Domestic Product (GDP)>$15,000) or middle/low-income (GDP<$15,000), and a multivariate linear regression model was used to determine the association between healthcare system indicators and cancer MIR. Indicators study included per capita GDP, overall total healthcare expenditure (THE), THE as a proportion of GDP, total external beam radiotherapy devices (TEBD) per capita, physician density, and the year 2000 WHO healthcare system rankings.
  
  
  RESULTS
  Cancer MIR in high-income countries (0.47) was significantly lower than that of middle/low-income countries (0.64), with a p<0.001. In high-income countries, GDP, health expenditure and TEBD showed significant inverse correlations with overall cancer MIR. A $3040 increase in GDP (p=0.004), a $379 increase in THE (p<0.001), or an increase of 0.59 TEBD per 100,000 population (p=0.027) were all associated with a 0.01 decrease in cancer MIR. In middle/low-income countries, only WHO scores correlated with decreased cancer MIR (p=0.022); 12 specific cancer types also showed similar significant correlations (p<0.05) as overall cancer MIR.
  
  
  CONCLUSIONS
  The analysis of this study suggested that cancer MIR is greater in middle/low-income countries. Furthermore, the WHO healthcare score was associated with improved cancer outcomes in middle/low-income countries while absolute levels of financial resources and infrastructure played a more important role in high-income countries.
authors.affiliation: Yale School of Medicine, New Haven, CT, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Batouli
authors.affiliation: Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
authors.forename: Pooya
authors.initials: P
authors.lastname: Jahanshahi
authors.affiliation: Yale School of Medicine, New Haven, CT, USA; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center at Yale, New Haven, CT, USA.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
authors.affiliation: United States Department of Veterans Affairs, Department of Urology, NYU Cancer Institute, New York University School of Medicine, New York, NY, USA.
authors.forename: Danil V
authors.initials: DV
authors.lastname: Makarov
authors.affiliation: Yale School of Medicine, New Haven, CT, USA; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center at Yale, New Haven, CT, USA. Electronic address: james.b.yu@yale.edu.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
mesh_terms: D014943:Global Health / Q000191:economics*; D059066:Gross Domestic Product / Q000706:statistics & numerical data*; D006295:Health Resources; D006305:Health Status Indicators; D006801:Humans; D009026:Mortality; D009369:Neoplasms / Q000453:epidemiology* / Q000517:prevention & control; D017063:Outcome Assessment, Health Care; D012923:Social Class
keywords: Cancer; Cancer incidence; Cancer mortality; Global cancer mortality; Healthcare expenditure; Healthcare infrastructure