Vacuole-mitochondrial crosstalk during apoptosis induced by acetic acid in yeast

This work was supported by the FCT project PTDC/BIA-BCM/69448/200

What yeast can tell us about how cells commit suicide?

Multicellular organisms developed a complex system to balance cell proliferation and cell death in order to guarantee correct embryonic development and tissue homeostasis. Failure of cells to undergo programmed cell death (PCD) can potentially lead to severe diseases, including neural degeneration, autoimmunity and cancer. Identifying the molecules involved in PCD and understanding the regulation of the process are crucial for prevention and management of these diseases. Evidence of the enormous impact of PCD, of which apoptosis is the most frequent morphological phenotype, on human health makes it one of the today’s main research topics. Since PCD was initially considered specific of metazoans, biological models were first restricted to animal cells. Actually, based on the absence of known crucial PCD regulators, as indicated by plain homologies searches, as well as on the difficulty to explain the sense of cell suicide in a unicellular organism, it was not accepted that these organisms could possess a PDC mechanism. However, evidence has been reported in the last decade indicating that the process of self-destruction in different unicellular organisms, namely in yeast, can also take place. In the present communication, I will present the research we have been developing on PCD, based on the exploration/exploitation of yeast as a simple eukaryotic unicellular model system. Particular focus will be given to our more recent studies suggesting a complex regulation and interplay between mitochondria and the vacuole in acetic acid induced PCD. The validation in mammalian cell lines of the hypothesis postulated with the yeast model will be also discussed.Fundação para a Ciência e a Tecnologia (FCT

SARS-CoV-2 introductions and early dynamics of the epidemic in Portugal

Genomic surveillance of SARS-CoV-2 in Portugal was rapidly implemented by the National Institute of Health in the early stages of the COVID-19 epidemic, in collaboration with more than 50 laboratories distributed nationwide. Methods By applying recent phylodynamic models that allow integration of individual-based travel history, we reconstructed and characterized the spatio-temporal dynamics of SARSCoV-2 introductions and early dissemination in Portugal. Results We detected at least 277 independent SARS-CoV-2 introductions, mostly from European countries (namely the United Kingdom, Spain, France, Italy, and Switzerland), which were consistent with the countries with the highest connectivity with Portugal. Although most introductions were estimated to have occurred during early March 2020, it is likely that SARS-CoV-2 was silently circulating in Portugal throughout February, before the first cases were confirmed. Conclusions Here we conclude that the earlier implementation of measures could have minimized the number of introductions and subsequent virus expansion in Portugal. This study lays the foundation for genomic epidemiology of SARS-CoV-2 in Portugal, and highlights the need for systematic and geographically-representative genomic surveillance.We gratefully acknowledge to Sara Hill and Nuno Faria (University of Oxford) and Joshua Quick and Nick Loman (University of Birmingham) for kindly providing us with the initial sets of Artic Network primers for NGS; Rafael Mamede (MRamirez team, IMM, Lisbon) for developing and sharing a bioinformatics script for sequence curation (https://github.com/rfm-targa/BioinfUtils); Philippe Lemey (KU Leuven) for providing guidance on the implementation of the phylodynamic models; Joshua L. Cherry (National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health) for providing guidance with the subsampling strategies; and all authors, originating and submitting laboratories who have contributed genome data on GISAID (https://www.gisaid.org/) on which part of this research is based. The opinions expressed in this article are those of the authors and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government. This study is co-funded by Fundação para a Ciência e Tecnologia and Agência de Investigação Clínica e Inovação Biomédica (234_596874175) on behalf of the Research 4 COVID-19 call. Some infrastructural resources used in this study come from the GenomePT project (POCI-01-0145-FEDER-022184), supported by COMPETE 2020 - Operational Programme for Competitiveness and Internationalisation (POCI), Lisboa Portugal Regional Operational Programme (Lisboa2020), Algarve Portugal Regional Operational Programme (CRESC Algarve2020), under the PORTUGAL 2020 Partnership Agreement, through the European Regional Development Fund (ERDF), and by Fundação para a Ciência e a Tecnologia (FCT).info:eu-repo/semantics/publishedVersio

Impact of mutated KRAS signalling on autophagy regulation in colorectal carcinoma

Programa Doutoral em Biologia Molecular e AmbientalColorectal carcinoma (CRC) is the third most commonly diagnosed cancer worldwide and one of the most abundant causes of cancer related deaths. KRAS mutations ( KRASG13D, KRASG12D and KRASG12V) are frequent events in CRC, detected in about 30% to 50% of the clinical cases, and seem to play an important role in colon carcinogenesis. It is known that KRAS mutations are predictive biomarkers for resistance of CRC to EGFR inhibitors, though the exact mechanism is poorly understood. Autophagy is a catabolic process evolutionarily conserved from yeast to mammals, used by the cells to maintain cellular homeostasis but deregulated in some cancers, including CRC. It has been implicated in both cancer initiation and progression, playing a pro-survival or a pro-death role, depending on the stage of carcinogenesis and on the type of cancer, and also in the resistance of tumours to chemotherapy. In the case of CRC development, the role of autophagy is controversial and poorly understood. Oncogenic RAS has been implicated in autophagy regulation with different outcomes in cancer progression depending on the cell context. However, little is known about the impact of mutated KRAS in autophagy regulation as well as the signalling pathways implicated in CRC and in normal colon cells, constituting an emerging field of research that needs further clarification. Understanding the role of mutated KRAS signalling in autophagy regulation in colon carcinogenesis may contribute to new perspectives for therapeutic approaches in resistant CRC harbouring KRAS mutations. In the present work, we aimed to investigate the precise contribution of activating KRAS mutations in autophagy regulation in normal and CRC cells, as well as the signalling pathways involved, and how this impacts cell survival. In order to achieve our goal, we established two “clean” cellular models that provide the advantage of studying these mutations in the same genetic background: the normal colonic epithelial cell (NCM460) model and the yeast S. cerevisiae model, where we individually overexpressed the different KRAS mutations ( KRASG13D, KRASG12D and KRASG12V) as well as the wild-type KRAS ( KRASWT). To complete our studies, we confirmed the results obtained in established patient-derived CRC cell lines: HCT116 and SW480, harbouring a KRASG13D and a KRASG12D mutation, respectively. We showed that expression of KRASG13D, KRASG12D and KRASG12V up-regulates autophagy to a greater extent than expression of KRASWT in both normal colon NCM460 cells and S. cerevisiae cells facing environmental stress like nutrient limitation. Accordingly, we found that inhibition of KRAS decreases the autophagic flux in CRC-derived cells HCT116 and SW480 under nutrient starvation conditions, decreasing the formation of the Atg5-Atg12 complex, LC3-II delivery to the lysosome and Beclin 1 levels, thus demonstrating that autophagy in these cells is KRAS-dependent. The fact that we obtained similar results regarding the role of KRAS in autophagy using the different cell systems validates our newly established “KRAS-humanized yeast” and normal colon cells stably expressing KRAS mutations as new cell models to study the role of mutated KRAS in colon carcinogenesis. We also identified KRAS signalling effectors involved in autophagy regulation in our cell models. In S. cerevisiae cells, KRAS-induced autophagy occurs via regulation of Tor1p and Sch9p, components of the TOR pathway. In normal NCM460 colon cells, KRAS-induced autophagy proceeds through up-regulation of the MEK/ERK pathway and down-regulation of the PI3K/AKT pathway. In accordance with the results obtained in the NCM460 cell model, suppression of KRAS decreased ERK phosphorylation in HCT116 and SW480 cells, and increased AKT phosphorylation in SW480 cells. Silencing of MEK1/2 and PIK3CA in SW480 cells further demonstrated that KRASinduced autophagy is dependent on up-regulation of the MEK/ERK pathway. Together, these data strongly support the hypothesis that KRAS-induced autophagy in CRC cells is dependent on the activation of the MEK/ERK pathway and inactivation of the PI3K/AKT/mTOR pathway. Our data also show that autophagy contributes to the survival of normal and CRC cells during starvation. We demonstrated that overexpression of KRASG13D, KRASG12D and KRASG12V increases the proliferative lifespan and survival of normal colon cells during starvation, consistent with the fact that KRAS mutations are important during adenoma progression in colorectal carcinogenesis. We also observed that CRC cells harbouring KRASG13D, PIK3CAH1047R mutations and EGFR overexpression seem to be more sensitive to autophagy inhibition during starvation than CRC cells with only a KRASG12V mutation. We therefore expect that our results might have relevant implications for redefinition of therapeutic approaches of CRC harbouring KRAS, PIK3CA mutations and overexpressing EGFR, which are resistant to EGFR inhibitors, as autophagy inhibitors might overcome the resistance of these CRCs with poor prognosis.O carcinoma colorretal (CCR) é o terceiro tipo de cancro mais diagnosticado e uma das principais causas de morte relacionadas com cancro. No CCR, as mutações KRASG13D, KRASG12D e KRASG12V são eventos frequentes, estando presentes em 30% a 50% dos casos clínicos e parecem desempenhar um papel crucial na carcinogénese do cólon. Sabe-se que mutações KRAS oncogénicas são marcadores biológicos preditivos de resistência à terapia do CCR com inibidores do EGFR. A autofagia é um processo catabólico evolutivamente conservado desde as leveduras até aos mamíferos, usado pelas células para manter a homeostasia celular e está desregulado em diversos cancros, incluindo o CCR. Tem sido implicada na iniciação e progressão do cancro, desempenhando um papel promotor de sobrevivência ou morte, dependendo da fase do processo carcinogénico e do tipo de cancro, bem como na resistência dos tumores à quimioterapia. No caso do desenvolvimento do CCR, o papel da autofagia é controverso e não é bem compreendido. O RAS oncogénico tem sido implicado na regulação da autofagia com diferentes respostas na progressão do cancro dependendo do contexto celular. Pouco se sabe sobre o impacto do KRAS mutado na regulação da autofagia, bem como das vias de sinalização implicadas no CCR e em células normais do cólon, sendo por isso uma linha de investigação emergente que necessita de esclarecimento. Compreender o papel da sinalização do KRAS mutado na regulação da autofagia na carcinogénese do cólon pode contribuir para novas abordagens terapêuticas nos CCR resistentes que possuem mutações no KRAS. Neste trabalho, pretendeu-se investigar a contribuição específica das mutações KRAS oncogénicas na regulação da autofagia em células normais e do CCR, bem como das vias de sinalização envolvidas e qual o impacto na sobrevivência celular. De modo a cumprir o nosso objetivo, estabelecemos dois novos modelos celulares “limpos” que têm como vantagem permitir o estudo destas mutações no mesmo “background” genético: o modelo de células epiteliais normais do cólon (NCM460) e o modelo da levedura Saccharomyces cerevisiae, nos quais expressamos individualmente os diferentes mutações do KRAS ( KRASG13D, KRASG12D e KRASG12V) bem como o KRAS selvagem ( KRASWT). Para completar o nosso estudo, confirmamos os resultados obtidos em linhas celulares estabelecidas derivadas de pacientes com CCR, HCT116 e SW480, contendo as mutações KRASG13D e KRASG12V, respetivamente. Mostramos que a expressão de KRASG13D, KRASG12D e KRASG12V nas células NCM460 e na levedura S. cerevisiae, quando sujeitas a um ambiente de stresse como privação de nutrientes, regula positivamente a autofagia comparativamente com a expressão de KRASWT. De igual modo, verificamos que a inibição de KRAS diminui o fluxo autofágico nas células derivadas de CCR, HCT116 e SW480, em condições de privação de nutriente, diminuindo a formação do complexo Atg5-Atg12, o transporte de LC3-II para o lisossoma e o nível de proteína Beclin 1, demonstrando que a autofagia é dependente do KRAS. A concordância dos resultados obtidos relativamente ao papel do KRAS na autofagia usando os diferente sistemas celulares valida o uso da recém estabelecida "levedura humanizada para o KRAS” e das células normais do cólon expressando as mutações do KRAS como novos modelos celulares para o estudo do papel do KRAS mutado na carcinogénese do cólon. Efetores da sinalização pelo KRAS envolvidos na regulação da autofagia nos nossos modelos celulares foram igualmente identificados. Nas células de S. cerevisiae, a autofagia induzida pelo KRAS ocorre via Tor1p e Sch9p, componentes da via TOR. Nas células normais do cólon NCM460, a autofagia induzida pelo KRAS ocorre através da regulação positiva da via MEK/ERK e da regulação negativa da via PI3K/AKT. Em concordância, a supressão do KRAS diminuiu a fosforilação das ERK nas células HCT116 e SW480, e aumentou a fosforilação do AKT nas células SW480. A supressão de MEK1/2 e PIK3CA nas células SW480 confirmou mais uma vez que a indução de autofagia pelo KRAS nas células CCR é dependente da ativação da via MEK/ERK. Estes dados apoiam a hipótese de que a autofagia induzida pelo KRAS em células CCR é dependente da ativação da via MEK/ERK e da inativação da via PI3K/AKT/mTOR. Os nossos dados mostram que a autofagia contribui para a sobrevivência das células normais do cólon e das células CCR durante a privação de nutrientes. Demonstramos que a sobreexpressão de KRASG13D, KRASG12D e KRASG12V aumenta o tempo de vida proliferativo e a sobrevivência de células normais do cólon, o que é consistente com o facto de serem importantes na progressão de adenoma na carcinogénese colorretal. As células de CCR contendo mutações KRASG13D, PIK3CAH1047R e sobreexpressão de EGFR parecerem ser mais sensíveis à inibição de autofagia durante a privação de nutrientes, do que as células CCR apenas com a mutação KRASG12V. Os resultados deste trabalho podem ter implicações relevantes nas abordagens terapêuticas do CCR contendo mutações KRAS, PIK3CA e sobreexpressão do EGFR, que conferem resistência a inibidores do EGFR, visto que inibidores da autofagia podem reverter a resistência destes CCRs de prognóstico reservado.A autora deste trabalho usufruiu de uma bolsa da Fundação para a Ciência e a tecnologia (FCT), com a referência SFRH/BD/64695/2009 co-financiada pelo FEDER através de POFC - COMPETE, e por fundos nacionais da FCT através do projecto PEst-C/BIA/UI4050/2011

Regulação da autofagia pelo KRAS de modo a compreender o seu papel no cancro humano

Tese de mestrado em Genética MolecularA evasão à morte celular programada (MCP) é uma das características dos cancros humanos. O papel da autofagia no cancro não é bem compreendido. Dependendo do tipo e contexto celulares, a autofagia pode actuar como um mecanismo supressor de tumor, induzindo a MCP, ou como um processo de sobrevivência. A mutação oncogénica KRAS está entre os eventos mais frequentes no carcinoma colorectal (CCR), ocorrendo em cerca de 50% dos tumores, contudo o seu papel na autofagia não está ainda completamente esclarecido. Estudos recentes mostraram que a proteína RAS pode ter efeitos opostos sobre a autofagia; quando activa a PI3K de classe I, a autofagia é inibida, mas quando activa a cascata RAF/ERK 1/2, a autofagia é estimulada. Várias vias de sinalização da levedura Saccharomyces cerevisiae são homólogas às encontradas nos humanos. Por este motivo, S. cerevisiae é um modelo eucariótico simples que tem sido utilizado para compreender os mecanismos básicos envolvidos em diferentes processos celulares, tais como a autofagia. Para avaliar o efeito das mutações do oncogene KRAS na regulação da autofagia no CCR, utilizamos o modelo da levedura S. cerevisiae para a expressão heteróloga da mutação humana KRASG13D e do gene selvagem KRASWT e avaliação dos níveis de autofagia, por monitorização de marcadores autofágicos. Os genes foram inseridos num vector de expressão em leveduras e as construções utilizadas para transformar uma estirpe de S. cerevisiae deficiente no gene RAS2, homólogo dos proto-oncogenes do RAS de mamíferos. Utilizou-se uma estirpe ras2Δ dado que na presença desta proteína não se detectou qualquer efeito do KRAS selvagem ou mutado na indução de autofagia. Adicionalmente, esta estirpe contém uma versão truncada do gene PHO8 (PHO8Δ60) em substituição do gene normal, o que permite a avaliação dos níveis de autofagia por monitorização da actividade da fosfatase alcalina (FAL). A autofagia foi também avaliada por monitorização da quantidade de Atg8p por análise de Western blotting. A mutação humana activante KRASG13D resultou numa indução da autofagia em S. cerevisiae em condições de privação de fonte de azoto. Por outro lado, a presença do gene humano selvagem KRASWT não levou a uma indução da autofagia. Este estudo aponta para a grande complexidade dos papéis do gene RAS na regulação da autofagia e valida a utilização da levedura como um modelo celular alternativo para o esclarecimento deste processo nomeadamente do seu papel no CCR.Evasion from programmed cell death (PCD) is one of the hallmarks of human cancers. The role of autophagy in human cancer is not well understood. Depending on the cell type and context autophagy may act either as a tumor suppressor mechanism, enhancing PCD or as a survival process. KRAS mutations are among the most frequent events in colorectal carcinoma (CRC) occurring in about 50% of the tumors. So far the role of RAS in autophagy is still elusive. However, a recent study has found that RAS may have opposite effects on autophagy; when it activates Class I PI3K, autophagy is inhibited, but when it activates the RAF /ERK1/2 cascade, autophagy is stimulated. Several signaling pathways of the yeast Saccharomyces cerevisiae are homologous to those found in humans. For this reason, the simple eukaryotic model S. cerevisiae has been used to understand the basic mechanisms involved in different cellular processes such as autophagy. To assess the effect of human KRAS mutations in autophagy regulation, we used the yeast S. cerevisiae cell model for heterologous expression of the human KRASG13D mutation, as well as wild type KRASWT gene and evaluation of levels of autophagy, by monitoring autophagic markers. These genes were cloned into expression plasmids in yeast and these constructs used to transform a S. cerevisiae strain deleted for RAS2, homologous of mammalian RAS protooncogenes. A ras2Δ strain was used since in the presence of the protein no effect of KRASWT or of KRASG13D in autophagy could be detected. Additionally, this strain carries a truncated version of PHO8 (PHO8Δ60) instead of the normal gene, to assess alkaline phosphatase whose activity is used as an indication of autophagic levels. We also assessed autophagy induction by monitoring the amount of Atg8p by Western blot analyses. The human KRASG13D mutation induced a significant increase of autophagy in S. cerevisiae upon nitrogen starvationOn the other hand, the presence of the human KRASWT failed to induce autophagy in the same conditions. In summary, this study points to the complexity of the role of RAS in the regulation of autophagy and validates the use of yeast as a cell model towards the elucidation of this issue, namely in CRC

Revisão sistematizada da literatura e opinião de peritos

Objective: The 3E (Evidence, Expertise, Exchange) Initiative is a multinational effort of rheumatologists aimed at developing evidence-based recommendations addressing specific questions relevant to clinical practice. The objective of the Portuguese contribution for the 3E Initiative was to develop evidence-based recommendations on how to investigate, follow-up and treat undifferentiated peripheral inflammatory arthritis (UPIA) adapted to local reality and develop additional recommendations considered relevant in the national context. Methods: An international scientific committee from 17 countries selected a set of questions concerning the diagnosis and monitoring of UPIA using a Delphi procedure. Evidence-based answers to each question were sought by a systematic literature search, performed in Medline, Embase, the Cochrane Library and ACR/EULAR 2007-2009 meeting abstracts. Relevant articles were reviewed for quality assessment, data extraction and synthesis. In a national meeting, a panel of 63 Portuguese rheumatologists used the evidence which was gathered to develop recommendations, and filled the gaps in the evidence with their expert opinion. Finally, national recommendations were formulated and agreement among the participants was assessed. Results: A total of 54754 references were identified, of which 267 were systematically reviewed. Thirteen national key recommendations about the investigation, follow-up and treatment of UPIA were formulated. One recommendation addressed differential diagnosis and investigations prior to the established operational diagnosis of UPIA, eight recommendations were related to the diagnostic and prognostic value of clinical and laboratory assessments in established UPIA (history and physical examination, acute phase reactants, serologies, autoantibodies, radiographs, magnetic resonance imaging and ultrasound, genetic markers and synovial biopsy), one recommendation highlighted predictors of persistence (chronicity), one addressed monitoring of clinical disease activity in UPIA, one aimed to find an useful method/score to predict a definitive diagnosis and the last one was related to treatment. Conclusion: Portuguese evidence-based recommendations for the management of UPIA in everyday practice were developed. Their dissemination and implementation in daily clinical practice should help to improve practice uniformity and optimize the management of UPIA patients.publishersversionpublishe

A multi-country analysis of COVID-19 hospitalizations by vaccination status

Background: Individuals vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), when infected, can still develop disease that requires hospitalization. It remains unclear whether these patients differ from hospitalized unvaccinated patients with regard to presentation, coexisting comorbidities, and outcomes. Methods: Here, we use data from an international consortium to study this question and assess whether differences between these groups are context specific. Data from 83,163 hospitalized COVID-19 patients (34,843 vaccinated, 48,320 unvaccinated) from 38 countries were analyzed. Findings: While typical symptoms were more often reported in unvaccinated patients, comorbidities, including some associated with worse prognosis in previous studies, were more common in vaccinated patients. Considerable between-country variation in both in-hospital fatality risk and vaccinated-versus-unvaccinated difference in this outcome was observed. Conclusions: These findings will inform allocation of healthcare resources in future surges as well as design of longer-term international studies to characterize changes in clinical profile of hospitalized COVID-19 patients related to vaccination history. Funding: This work was made possible by the UK Foreign, Commonwealth and Development Office and Wellcome (215091/Z/18/Z, 222410/Z/21/Z, 225288/Z/22/Z, and 220757/Z/20/Z); the Bill & Melinda Gates Foundation (OPP1209135); and the philanthropic support of the donors to the University of Oxford's COVID-19 Research Response Fund (0009109). Additional funders are listed in the "acknowledgments" section

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.The aim of this study was to inform vaccination prioritization by modelling the impact of vaccination on elective inpatient surgery. The study found that patients aged at least 70 years needing elective surgery should be prioritized alongside other high-risk groups during early vaccination programmes. Once vaccines are rolled out to younger populations, prioritizing surgical patients is advantageous

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research