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Treatment of solid tumors consists of a multi-disciplinary approach with surgical resection as the cornerstone of treatment for many cancer types. Improvement in the surgical outcome of cancer can only be achieved with the development of new combined, evidence based treatment strategies. Scientific research in the field of surgical oncology is important for the expansion of knowledge and for the improvement of multimodality cancer treatment. The amount of effort spend by researchers to study cancer and the financial investment brought up by governmental and private sector sources, has been accumulating worldwide. Obviously, the scientific contribution to the field of surgical oncology is not equal for each country, since different countries hold different healthcare systems, financial research sources and scientific research programs. In order to obtain insight in the distribution between the scientific contributions of countries, rankings have been made through Journal Citation Reports for universities and different fields of medicine 1. Ranking of countries according their scientific literature contribution has been performed for anesthesia and critical care medicine, pathology, ophthalmology, respiratory medicine, dermatology, radiology, gynecology, oncology, orthopedic surgery, and general surgery but the field of surgical oncology is lacking. For this article an international ranking for the field of surgical oncology was made based on the geographical distribution of publications in this field. All peer-reviewed journals with an impact factor above 1.0, both assigned to the "oncology" and the "surgery" category according the 2012 journal citation reports established by the Institute for Scientific Information, were included 1. The six selected journals were: Annals of Surgical Oncology, European Journal of Surgical Oncology, Surgical Oncology, Journal of Surgical Oncology, Surgical Oncology Clinics of North America, and World Journal of Surgical Oncology. All articles with an abstract in the PubMed NCBI journal database 2 were registered by country of origin over a 10-year period (2001–2010) and ranked according five categories: mean impact factor, number of publications per 106 inhabitants 3, number of publications per annual number of new cancer patients per 100,000 inhabitants 4, total number of publications and number of publications per percent of gross domestic product spent on research and development 5. Subsequently, the ranking of the five categories was summed to lead to a final ranking. A total of 8,742 publications were selected (Tables I and II). The top three countries accounted for 36.4% of publications and the United States of America (USA) produced 26.9% of the total amount. The total number of publications was the highest for the USA (2,349), Japan (854), and the United Kingdom (717, Fig. 1). The mean impact factor of registered publications was the highest for Australia, Taiwan, and the USA, with a mean impact factor of 3.24, 3.14, and 3.08, respectively. The top three countries with the highest publication rate per 106 inhabitants were the Netherlands, Ireland, and Greece. Considering the countries' cancer incidence rates, the USA, India, and Japan showed the highest number of publications for each new cancer patient on 100,000 inhabitants per year. The USA, Italy, and the United Kingdom showed the highest number of publications per percentage of gross domestic product that countries spent on research and development (Fig. 2). Summing the ranks of these five categories resulted in the final ranking. The top three most prolific countries in the field of surgical oncology were: the USA (1), the Netherlands (2), and Taiwan (3). Furthermore, we analyzed the correlation between the total amount of publications and the number of inhabitants, the annual cancer incidence and the percentage of gross domestic product spent on research and development, per country (Table III). The financial investment reflected in percentage of gross domestic product, was not significantly correlated with the total amount of publications. The number of inhabitants per country and the annual cancer incidence, however, were significantly correlated with the total number of publications per country (R = 0.571 and 0.658, respectively). In absolute numbers the USA is the most productive country in the majority of studies, which was also confirmed in the present study. The USA its large population size, English language, and hosting of high-ranked journals, will likely contribute to this prolific success. The high ranking of the Netherlands was derived from its relative high number of publications for this relative small country, while Taiwan published in relatively high impact factor journals. According to our results of the correlation analyses, scientific contribution by country does not seem to improve by investing more money. However, the total amount of inhabitants per country and exposure and interest concomitant with higher cancer incidence, seem to have a significant influence on the scientific productivity of a country. There are some limitations worth mentioning in studies investigating geographical distribution and country ranking of scientific research. In our analysis the selection of scientific journals was limited. High impact journals, such as The New England Journal of Medicine, Lancet Oncology, the Lancet, the Journal of Clinical Oncology, and the Annals of Surgery, publish regularly articles in the field of surgical oncology. However, it is difficult to determine which specific publications in those journals are eligible. We hypothesized that the scientific distribution by countries, found in these journals, can be extrapolated to other journals. Though there are some limitations, due to the present analyses, it is possible to rank the countries according the chosen five categories. It is thought that these categories give a good reflection of the scientific contribution per country. Therefore, the obtained results provide insight in the distribution of geographical origin of research production in the different medical fields. In conclusion, publishing scientific results remains of great importance in sharing knowledge worldwide and improving healthcare. The disclosure and publication of scientific results obtained in different fields of medical research, is not equally distributed between countries. In the field of surgical oncology, the USA, the Netherlands, and Taiwan, three countries on three different continents have the greatest prolific success. Investing more money, by raising government expoenditure on education and research, does not seem to improve scientific output. Cancer incidence and country population do appear to have a significant impact on the scientific contribution to the scientific field of surgical oncology.
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