Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

James B. Yu

Subject Area(s)

Epidemiology, Oncology


Cancer continues to rise steadily as a contributor to premature death in the developing world. Despite this, little is known about what aspects of national healthcare systems are associated with reduced mortality from cancer. Thus, we aimed to investigate the relationship between national healthcare system resources and cancer mortality. The most recent estimates of cancer incidence and deaths were obtained for the 85 countries with reliable data. We defined cancer mortality to incidence ratio as deaths per year divided by incidence per year for a given cancer. Countries were categorized according to high (GDP>$15,000) or low-income (GDP<$15,000), and a multivariate linear regression model was used to determine the association between healthcare system indicators and cancer-specific mortality to survival ratio. Indicators studied included per capita gross domestic product (GDP), overall healthcare expenditure, health expenditure as a proportion of GDP, total external beam radiotherapy devices per capita (TEBD), physician density, and the year 2000 World Health Organization (WHO) healthcare system rankings.

The overall cancer mortality to survival ratio in high income countries (47%) was significantly lower than that of low income countries (64%), with a p<0.0001. In high income countries, GDP, health expenditure and TEBD showed significant inverse correlations with overall cancer mortality to survival ratio, with health expenditure(overall and as a proportion of GDP) showing the strongest relationship. For overall cancer, a $3,040 increase in GDP (p=0.004), a $379 increase in THE (p<0.0001), a 0.75% increase in THE per GDP (p<0.001) or an increase of 0.59 TEBD 100,000 population (p=0.027) were all associated with a 1% decrease in mortality to survival ratio. In low income countries, only WHO score correlated with decreased overall cancer mortality to survival ratio (p=0.022).

Our analysis suggests that WHO healthcare score is associated with improved cancer outcomes in low income countries while absolute levels of financial resources and infrastructure play a more important role in high income countries.


This is an Open Access Thesis.

Open Access

This Article is Open Access