Cebu Institute of Medicine

Objective:Significant global health disparities persist in cervical cancer, with over 85% of cases and deaths occurring in low- and middle-income countries (LMICs). In many settings, access to screening, vaccination and treatment is limited. Despite cervical cancer being largely preventable through human papillomavirus (HPV) vaccination and early detection, many women around the world face inadequate healthcare infrastructure, lack of awareness, cultural stigma and gender barriers to seeking care. Therefore, we evaluated global health system metrics that may inform efforts to improve equity in access to cervical cancer care globally. Methods and analysis:We derived estimates of age-standardised mortality-to-incidence ratios (MIRs) for female patients with cervical cancer of all ages from the Global Cancer Observatory (GLOBOCAN 2022 database), with complete data available for 121 of 185 countries in the database. We selected the following health system metrics: health spending as a per cent of gross domestic product (GDP), physicians/1000 population, nurses and midwives/1000 population, surgical workforce/1000 population, GDP per capita, Universal Health Coverage Service Coverage Index (UHC index), availability of pathology services, Human Development Index (HDI), Gender Inequality Index (GII) (a combined metric of health, empowerment and economic agency), radiotherapy centres/1000 population, out-of-pocket expenditure as percentage of current health expenditure, availability of cervical cancer screening, and HPV coverage.We evaluated the association between MIR and each metric using univariable linear regressions. To account for multiple comparisons, a Bonferroni correction using a p<0.0045 was applied. Metrics meeting this threshold were included in multivariable models. Variation inflation factor (VIF) allowed exclusion of variables with significant multicollinearity. R2 defined goodness of fit.Subgroup analysis was done by country income level using 2025 World Bank classifications. Separate regression models were then done for high-income and low-middle-income countries. Results:On univariable analysis, 12 of the 13 metrics were significantly associated with MIR of cancer (p<0.001 for all). HPV coverage was not significantly associated with MIR (β=-0.0007, p=0.290). After including metrics that were significant on univariable analysis, HDI demonstrated significant collinearity (VIF=19). Therefore, after correcting for multicollinearity, the final multivariable model with 11 variables had R2 of 0.81.On multivariable analysis, the following variables were independently associated with lower (improved) MIR for cancer: (1) nurses/midwives per 1000 population (β=-0.0072, p=0.029) and (2) UHC index (β=-0.0022, p=0.026). In addition, greater gender inequality was associated with greater (worse) MIR (β=0.30, p=0.003). Further subgroup analysis by income classification showed that GII remained significantly associated with lower MIRs among HICs (β=-0.526, p=0.033), and only UHC index was significantly associated among LMICs (β=-0.0023, p=0.047). Conclusion:This comprehensive and global analysis of health system metrics suggests promoting progress towards UHC and strengthening the nursing/midwifery workforce may be independently associated with improved cervical cancer MIR. Furthermore, greater gender inequality was associated with worse MIR. These findings may inform efforts to improve global cervical cancer care and underscore the importance of reducing gender inequality to improve global cervical cancer outcomes.

Background Premature termination of cardiovascular trials undermines evidence generation and wastes resources. Objectives The objective of the study was to evaluate trends, predictors, and recruitment adequacy among prematurely terminated cardiovascular trials. Methods We analyzed adult cardiovascular trials registered on ClinicalTrials.gov (2000-2025). Trial characteristics, early termination, and reported reasons were extracted. Computed low recruitment was defined as actual enrollment <80% of target. Multivariable logistic regression identified independent predictors of termination. Results Among 19,191 trials, 2,202 (11.5%) were prematurely terminated. Low recruitment was the most common reported reason (946/2,202, 42.9%), yet 625/1,571 (39.9%) underenrolled trials did not report recruitment failure. Termination peaked in 2020 (155/1,033, 15.0%). Termination risk was the highest in early-phase trials (phases 1/2 or 2; 371/2,325, 16.0%) and lowest for behavioral/lifestyle interventions (146/2,998, 4.9%) and female-only trials (23/475, 4.8%). In multivariable analysis, small sample size (1-100 participants; OR: 3.37; 95% CI: 2.98-3.80) and later-phase trials (phase 2/3 or 3; OR: 1.69; 95% CI: 1.41-1.97) were associated with higher odds of termination, whereas behavioral/lifestyle interventions (OR: 0.40; 95% CI: 0.32-0.49), crossover designs (OR: 0.53; 95% CI: 0.42-0.65), and non-U.S. government funding (OR: 0.50; 95% CI: 0.31-0.78) were protective. Conclusions More than 1 in 10 cardiovascular trials terminate early, most often due to poor recruitment, which is frequently under-reported. Improved feasibility assessment and transparent reporting are needed. (Trends and Predictors of Premature Termination of Cardiovascular Trials: A Systematic Review; CRD420251155096)

OBJECTIVES:Head and neck cancer (HNC) remains a major global cause of cancer morbidity and mortality, with disproportionately poor outcomes in low- and middle-income countries. Substantial cross-national disparities suggest an important role for health system strengthening. We evaluated associations between national health system characteristics and global HNC outcomes. METHODS:We conducted a cross-sectional ecological analysis of 185 countries using sex-stratified, age-standardized incidence and mortality estimates from the International Agency for Research on Cancer (IARC) GLOBOCAN 2022 database. The primary outcome was the composite mortality-to-incidence ratio (MIR) for aggregated HNCs, including cancers of the lip and oral cavity, oropharynx, larynx, nasopharynx, hypopharynx, and salivary gland. Eleven national health system indicators capturing health financing, workforce density, service availability, socioeconomic development, and gender equity were evaluated. Univariable linear regressions identified candidate variables using Bonferroni correction (p < 0.0045), followed by multivariable modeling with assessment for multicollinearity using variance inflation factors. RESULTS:All 11 health system indicators were significantly associated with HNC MIR on univariable analysis (p < 0.001 for all). In multivariable analysis of 123 countries with complete data, higher Universal Health Coverage (UHC) service coverage index and higher gross domestic product (GDP) per capita were independently associated with lower (improved) HNC MIR (model R2 = 0.70). Findings were consistent in sex-stratified analyses. CONCLUSIONS:Across countries, progress toward universal health coverage and greater national economic capacity was independently associated with improved HNC outcomes. These findings may help to inform efforts at the level of health systems to improve HNC outcomes worldwide. LEVEL OF EVIDENCE:N/A.

PURPOSE:Gender inequality shapes women's cancer outcomes through social, economic, and health system factors. This study disaggregated the Gender Inequality Index (GII) to identify which dimensions-reproductive health, educational attainment, workforce participation, and political empowerment-independently influence global female cancer outcomes. METHODS:We conducted an ecologic, cross-national analysis using data from 185 countries. Age-standardized female cancer mortality-to-incidence ratios (MIRs) were derived from GLOBOCAN 2022. Independent variables included the composite GII and its five components: maternal mortality ratio, adolescent birth rate, female secondary education, labor force participation, and parliamentary representation. Univariable (Bonferroni-corrected significance threshold α = .01) and multivariable (α = .05) linear regressions assessed associations between these indicators and MIR, adjusting for health system variables including universal health coverage (UHC) index, gross domestic product (GDP) per capita, workforce availability, health spending, and radiotherapy access. RESULTS:Univariable analyses showed that GII and all components associated with higher MIR (P < .001 for all except labor participation, P = .026). Upon examining GII components in a multivariable model, higher adolescent birth rate (β = .0014, P < .001), lower female secondary education (β = -.0020, P < .001), and lower women's parliamentary representation (β = -.0022, P < .001) were independently associated with higher female MIR (N = 168, R2 = 0.70). In fully adjusted models accounting for national wealth and system capacity (N = 124, R2 = 0.88), higher UHC index (P < .001) and GDP per capita (P = .007) predicted lower MIR, while adolescent birth rate may be positively associated (P = .084). CONCLUSION:Structural gender inequalities, particularly those related to reproductive burden, education, and political representation, are linked to poorer female cancer outcomes. Advancing gender equity through reproductive health access, girls' education, and women's leadership is integral to improving cancer outcomes globally.