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患者特征、疾病或治疗能否解释结直肠癌生存方面的社会不平等现象?

Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer?

作者信息

Frederiksen Birgitte Lidegaard, Osler Merete, Harling Henrik, Ladelund Steen, Jørgensen Torben

机构信息

Research Centre for Prevention and Health, Capital Region of Denmark, Glostrup, Denmark.

出版信息

Soc Sci Med. 2009 Oct;69(7):1107-15. doi: 10.1016/j.socscimed.2009.07.040. Epub 2009 Aug 18.

Abstract

This paper investigates the association between individually measured socioeconomic status (SES) and all-cause survival in colorectal cancer patients, and explores whether factors related to the patient, the disease, or the surgical treatment mediate the observed social gradient. The data were derived from a nationwide clinical database of all adenocarcinomas of the colon or rectum diagnosed in Denmark between 2001 and 2004 (inclusive). These data were linked to those from several central registries providing information on income, education, and housing status, as well as to data on comorbidity from previous hospitalizations and use of medication. Only patients with colorectal cancer as their first primary tumour and those born after 1920 were included. A total of 8763 patients were included in the study. Cox proportional hazard regression models revealed a positive social gradient in survival for increasing levels of education and income, and in owners versus renters of housing. A series of regression analyses were used to test potential mediators of the association between the socioeconomic indicators and survival by stepwise inclusion of lifestyle factors (smoking, alcohol intake, body mass index), comorbidity, stage of disease, mode of admission, type of operation, specialization of the surgeon, and curative versus palliative resection. A causal diagram guided the analyses. Inclusion of comorbidity, and to a lesser extent lifestyle, reduced the variation associated with SES, while no evidence of a mediating effect was found for disease or surgical treatment factors. This indicates that the difference in survival among colorectal cancer patients from different social groups was probably not caused by unintentional differences in treatment factors related to surgery, and suggests that primary prevention of chronic diseases among the socially deprived might be one way to reduce social differences in prognosis.

摘要

本文研究了个体测量的社会经济地位(SES)与结直肠癌患者全因生存率之间的关联,并探讨了与患者、疾病或手术治疗相关的因素是否介导了所观察到的社会梯度。数据来源于丹麦2001年至2004年(含)期间诊断的所有结肠或直肠癌腺癌的全国临床数据库。这些数据与几个中央登记处的数据相链接,这些登记处提供了有关收入、教育和住房状况的信息,以及与既往住院合并症和用药情况的数据。仅纳入以结直肠癌为其首个原发性肿瘤且出生于1920年以后的患者。共有8763名患者纳入本研究。Cox比例风险回归模型显示,随着教育水平和收入的提高,以及房屋所有者与租户相比,生存率存在正向社会梯度。通过逐步纳入生活方式因素(吸烟、饮酒、体重指数)、合并症、疾病分期、入院方式、手术类型、外科医生的专业程度以及根治性与姑息性切除,采用一系列回归分析来检验社会经济指标与生存率之间关联的潜在中介因素。分析由因果图指导。纳入合并症以及在较小程度上纳入生活方式,减少了与SES相关的差异,而未发现疾病或手术治疗因素有中介作用的证据。这表明不同社会群体的结直肠癌患者生存率差异可能并非由与手术相关的治疗因素的无意差异所致,并提示在社会弱势群体中对慢性病进行一级预防可能是减少预后社会差异的一种方法。

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