Send to

Choose Destination
J Epidemiol Glob Health. 2014 Jun;4(2):115-24. doi: 10.1016/j.jegh.2013.10.004. Epub 2013 Dec 28.

The global cancer divide: relationships between national healthcare resources and cancer outcomes in high-income vs. middle- and low-income countries.

Author information

Yale School of Medicine, New Haven, CT, USA.
Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
Yale School of Medicine, New Haven, CT, USA; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center at Yale, New Haven, CT, USA.
United States Department of Veterans Affairs, Department of Urology, NYU Cancer Institute, New York University School of Medicine, New York, NY, USA.
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:



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.


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.


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.


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.


Cancer; Cancer incidence; Cancer mortality; Global cancer mortality; Healthcare expenditure; Healthcare infrastructure

[Indexed for MEDLINE]
Free full text

Supplemental Content

Full text links

Icon for Elsevier Science
Loading ...
Support Center