Cho Hyunsoon, Mariotto Angela B, Schwartz Lisa M, Luo Jun, Woloshin Steven
Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD (HC, ABM); Division of Cancer Registration and Surveillance, National Cancer Center, Goyang-si Gyeonggi-do, Korea (HC); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, Geisel School of Medicine at Dartmouth, Hanover NH, Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT (LMS, SW); Information Management Services, Inc., Calverton, MD (JL).
J Natl Cancer Inst Monogr. 2014 Nov;2014(49):187-97. doi: 10.1093/jncimonographs/lgu014.
It is often assumed that increases in cancer survival reflect true progress against cancer. This is true when these increases are accompanied by decreased burden of disease: Fewer people being diagnosed or dying from cancer (ie, decreased incidence and mortality). But increased survival can also occur even when incidence is increasing and mortality is unchanged.
To use trends in cancer burden-incidence and mortality-to illustrate when changes in survival reflect true progress.
Using data from 1975 to 2010 collected by the Surveillance, Epidemiology, and End Results Program (incidence, survival) and the National Center for Health Statistics (mortality), we analyzed US trends in five-year relative survival, age-adjusted incidence, and mortality for selected cancers to identify patterns that do and do not reflect progress.
Among the nine common cancers examined, survival increased in seven, and changed little or not at all for two. In some cases, increased survival was accompanied by decreased burden of disease, reflecting true progress. For example, from 1975 to 2010, five-year survival for colon cancer patients improved (from 48% to 68%) while cancer burden fell: Fewer cases (incidence decreased from 60 to 41 per 100,000) and fewer deaths (mortality decreased from 28 to 16 per 100,000), a pattern explained by both increased early detection (with removal of cancer precursors) and more effective treatment. In other cases, however, increased survival did not reflect true progress. In melanoma, kidney, and thyroid cancer, five-year survival increased but incidence increased with no change in mortality. This pattern suggests overdiagnosis from increased early detection, an increase in cancer burden.
Changes in survival must be interpreted in the context of incidence and mortality. Increased survival only represents progress when accompanied by a reduction in incidence, mortality, or ideally both.
人们常常认为癌症生存率的提高反映了对抗癌症的真正进展。当生存率的提高伴随着疾病负担减轻时，情况确实如此：被诊断患有癌症或死于癌症的人数减少（即发病率和死亡率降低）。但即使发病率上升而死亡率不变，生存率也可能提高。
利用癌症负担（发病率和死亡率）的趋势来说明生存率的变化何时反映了真正的进展。
利用监测、流行病学和最终结果计划（发病率、生存率）以及国家卫生统计中心（死亡率）收集的1975年至2010年的数据，我们分析了美国选定癌症的五年相对生存率、年龄调整发病率和死亡率趋势，以确定反映和不反映进展的模式。
在所研究的九种常见癌症中，七种癌症的生存率有所提高，两种癌症的生存率变化很小或几乎没有变化。在某些情况下，生存率的提高伴随着疾病负担的减轻，反映了真正的进展。例如，从1975年到2010年，结肠癌患者的五年生存率有所提高（从48%提高到68%），而癌症负担下降：病例减少（发病率从每10万人60例降至41例），死亡人数减少（死亡率从每10万人28例降至16例），这种模式可归因于早期检测增加（切除癌前病变）和更有效的治疗。然而，在其他情况下，生存率的提高并不反映真正的进展。在黑色素瘤、肾癌和甲状腺癌中，五年生存率提高，但发病率上升而死亡率没有变化。这种模式表明早期检测增加导致了过度诊断，癌症负担增加。
生存率的变化必须结合发病率和死亡率来解释。只有在发病率、死亡率降低，或者理想情况下两者都降低的情况下，生存率的提高才代表进展。
