Ann Surg Oncol
https://doi.org/10.1245/s10434-018-6426-5
LETTER – HEALTH SERVICES RESEARCH AND GLOBAL ONCOLOGY
Alternative Ways to Study Global Variation in Cancer-Related
Research Activity
Anton Barchuk1,2 and Vadim Gushchin3
1
Epidemiology Group, Faculty of Social Sciences, University of Tampere, Tampere, Finland; 2Petrov National Research
Medical Center of Oncology, Saint Petersburg, Russia; 3Institute for Cancer Care at Mercy, Baltimore
We read with great interest the article by Are et al.,
entitled ‘‘Global Variations in the Level of Cancer-Related
Research Activity and Correlation to Cancer-Specific
Mortality: Proposal for a Global Curriculum.’’1 This article
was designed to analyze global variations in the level of
cancer-related research activity and correlate it with vari-
ations in cancer-specific mortality. We are interested in this
topic, because we are promoting high-quality, clinical
research activities in Russia through specific educational
programs and dissemination of research methodology in
clinical oncology.
While we fully agree that cancer-related research
activity as well as research literacy is an important factor in
establishing high-quality and sustainable cancer care, we
would like to draw attention to difficulties and possible
pitfalls in the quantitative assessment of the above-men-
tioned domains.2
Are et al. suggested that the number of country-specific
publications could be correlated to the changes in cancer
mortality. While the absolute number of publication is an
important indicator of research activity, we would cau-
tiously apply it in comparative analysis without a proper
denominator. Calculating the number of publications per
capita dramatically changes the country ratings. In Are
et al., the top ten publications by country were United
States, Japan, Germany, China, United Kingdom, Italy,
France, Canada, Spain, and Netherlands. After applying the
denominator of population size (World Bank population in
2006), the top ten countries were Iceland, Switzerland,
Ó Society of Surgical Oncology 2018
First Received: 12 February 2018
V. Gushchin
e-mail: vgushchin@mdmercy.com
Sweden, Denmark, Netherlands, Norway, Finland, Austria,
Belgium, and Israel. We believe that the latter list better
reflects the current situation with dedication to research
within the countries. Another issue of this indicator briefly
mentioned by Are et al. is not the amount but the quality of
research could be the key predictor of improved health-
related outcomes.
Overall cancer mortality trends are affected by multiple
factors, including risk factor prevalence, disease burden,
and the quality of registries. Sometimes increasing mor-
tality reflects the growing quality of causes of death
ascertainment, which can in fact reflect positive trends in
research and healthcare. Rapid changes in mortality, con-
versely, may reflect changes in registration procedures.3
Are et al. mentioned that research across a wide range of
disciplines improves cancer-specific survival, so we were
wondering if net survival could be applied instead of
changes in cancer mortality. We plotted the number of
publications per 100,000 population and net survival
available from the recent CONCORD-3 analysis.4 Then,
publication activity positively correlated with survival
only, for certain types of cancer with known progress in
diagnostic and treatment methods (melanoma and col-
orectal cancer), whereas countries with higher research
activity report lower survival for pancreatic and esophageal
cancers (Fig. 1).
Although the improved research activity in oncology is a
laudable and understandable goal, we would be very cau-
tious in the interpretation of the results of any ecological
analysis due to known limitations.5 Rather, we would focus
on other methods to analyze global variations in the level
of cancer-related research activity, such as the number of
randomized trials initiated and sponsored by academia and
clinical facilities.6 For example, to our knowledge there is
only one randomized study in the field of surgical oncology
currently recruiting patients in Russia (ClinicalTrials.gov

FIG. 1 Number of publications per 100,000 population and age-standardized 5-year net survival (%) in adults (15–99 years) diagnosed with one
of eight malignancies (oesophagus, stomach, colon, rectum, liver, pancreas, lung, and melanoma of the skin)
Identifier: NCT03009227). The number of highly cited
reports based on randomized trials in Russia was previ-
ously limited only to breast cancer research.7
In conclusion, we support Are et al. in attempts to
promote global curriculum in research literacy for the
surgical oncologist. At the same time, validated indicators
and high-quality research are needed to access quantita-
tively the need for such curriculum.
REFERENCES
1. Are C, Caniglia A, Mohammed M, et al. Global variations in the
level of cancer-related research activity and correlation to cancer-
specific mortality: proposal for a global curriculum. Ann Surg
Oncol. 2018;25(3):594–603. https://doi.org/10.1245/s10434-017-
6276-6.
2. Are C, Yanala U, Malhotra G, et al. Global curriculum in research
literacy for the surgical oncologist. Ann Surg Oncol.
2017;25(3):604–16. https://doi.org/10.1245/s10434-017-6277-5.
A. Barchuk, V. Gushchin
3. Parkin DM, Bray F. Evaluation of data quality in the cancer
registry: principles and methods part II. Completeness. Eur J
Cancer. 2009;45(5):756–64. https://doi.org/10.1016/j.ejca.2008.
11.033.
4. Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of
trends in cancer survival 2000–14 (CONCORD-3): analysis of
individual records for 37,513,025 patients diagnosed with one of
18 cancers from 322 population-based registries in 71 countries.
Lancet. 2018. https://doi.org/10.1016/s0140-6736(17)33326-3.
5. Rezaeian M. A call for revising the strengthening the reporting of
observational studies in epidemiology statement to include
ecologic studies. J Clin Epidemiol. 2014;67(7):836–7. https://doi.
org/10.1016/j.jclinepi.2014.02.010.
6. Vlassov V. Is there epidemiology in Russia? J Epidemiol
Community Health. 2000;54(10):740–4. https://doi.org/10.1136/
jech.54.10.740.
7. Semiglazov VF, Topuzov EE, Bavli JL, et al. Primary (neoadju-
vant) chemotherapy and radiotherapy compared with primary
radiotherapy alone in stage IIb–IIIa breast cancer. Ann Oncol.
1994;5(7):591–5.