Country-level right-to-health and health-system indicators and five-year net survival from adult brain tumours: An ecological analysis using CONCORD-3 data.

BACKGROUND

Country-level right-to-health and health-system indicators, mapped to availability, accessibility, acceptability and quality (AAAQ) domains, are used to evaluate equitable cancer outcomes, but their disease-specific validity is uncertain. Adult brain tumours are a stringent test case: no validated screening exists, glioblastoma drives much brain-tumour mortality, and survival depends on neurosurgical and radiotherapy access, neuropathology and molecular classification.

METHODS

Ecological analysis of five-year net survival from CONCORD-3 (adult C71 brain tumours, diagnosed 2010-14) and histology-resolved secondary outcomes (glioblastoma, diffuse and anaplastic astrocytoma, oligodendroglioma). Exposures were 14 country-level right-to-health, AAAQ-mapped, health-system and macroeconomic indicators (10 continuous, 4 binary). Pearson and Spearman correlations used bootstrap 95% confidence intervals and, per continuous non-GDP indicator, ordinary least-squares regression adjusted for log-GDP per capita (HC3 standard errors). Significance used analytic p values with Benjamini-Hochberg false-discovery-rate (FDR) correction across the full family (96 tests). Sensitivity analyses used high-income and European subsets and income-group adjustment.

RESULTS

Of 68 countries, 57 had adult brain survival data and 43 entered the primary analysis after excluding less reliable estimates. No association survived FDR correction at either level (smallest within-outcome q = 0.36; smallest full-family q = 0.59); the largest correlations were morphine consumption (r = +0.28, 95% CI +0.01 to +0.53), GDP per capita (+0.26, -0.03 to +0.54) and current health expenditure per capita (+0.23, -0.12 to +0.53). After log-GDP adjustment, no non-GDP indicator retained a significant association.

CONCLUSION

Generic country-level AAAQ-mapped indicators did not capture neuro-oncology pathway performance and showed no FDR-robust association with adult brain tumour survival; disease-specific pathway indicators are likely required.

POLICY SUMMARY: Policy frameworks relying on macro-indicators may misallocate accountability for brain tumour outcomes. Harmonised neuro-oncology pathway indicators (time to imaging and resection, completeness of molecular diagnosis, fidelity of evidence-based chemoradiation, neuro-palliative care integration) should be considered for international cancer-system and right-to-health monitoring.