Comber Harry, Sharp Linda, de Camargo Cancela Marianna, Haase Trutz, Johnson Howard, Pratschke Jonathan
National Cancer Registry, Cork, T12 CDF7, Ireland.
Institute of Health & Society, Newcastle University, United Kingdom.
Int J Cancer. 2016 Sep 1;139(5):1031-9. doi: 10.1002/ijc.30149. Epub 2016 May 5.
Emergency presentation of rectal cancer carries a relatively poor prognosis, but the roles and interactions of causative factors remain unclear. We describe an innovative statistical approach which distinguishes between direct and indirect effects of a number of contextual, patient and tumour factors on emergency presentation and outcome of rectal cancer. All patients diagnosed with rectal cancer in Ireland 2004-2008 were included. Registry information, linked to hospital discharge data, provided data on patient demographics, comorbidity and health insurance; population density and deprivation of area of residence; tumour type, site, grade and stage; treatment type and optimality; and emergency presentation and hospital caseload. Data were modelled using a structural equation model with a discrete-time survival outcome, allowing us to estimate direct and mediated effects of the above factors on hazard, and their inter-relationships. Two thousand seven hundred and fifty patients were included in the analysis. Around 12% had emergency presentations, which increased hazard by 80%. Affluence, private patient status and being married reduced hazard indirectly by reducing emergency presentation. Older patients had more emergency presentations, while married patients, private patients or those living in less deprived areas had fewer than expected. Patients presenting as an emergency were less likely to receive optimal treatment or to have this in a high caseload hospital. Apart from stage, emergency admission was the strongest determinant of poor survival. The factors contributing to emergency admission in this study are similar to those associated with diagnostic delay. The socio-economic gradient found suggests that patient education and earlier access to endoscopic investigation for public patients could reduce emergency presentation.
直肠癌的急诊表现预后相对较差，但致病因素的作用及相互关系仍不明确。我们描述了一种创新的统计方法，该方法可区分多种背景、患者和肿瘤因素对直肠癌急诊表现及预后的直接和间接影响。纳入了2004年至2008年在爱尔兰诊断为直肠癌的所有患者。与医院出院数据相关联的登记信息提供了关于患者人口统计学、合并症和健康保险的数据；居住地区的人口密度和贫困程度；肿瘤类型、部位、分级和分期；治疗类型及优化程度；以及急诊表现和医院病例量。使用具有离散时间生存结局的结构方程模型对数据进行建模，使我们能够估计上述因素对风险的直接和介导影响及其相互关系。2750名患者纳入分析。约12%的患者有急诊表现，这使风险增加了80%。富裕、私人患者身份和已婚通过减少急诊表现间接降低了风险。老年患者急诊表现更多，而已婚患者、私人患者或居住在贫困程度较低地区的患者急诊表现少于预期。以急诊就诊的患者接受优化治疗或在病例量高的医院接受治疗的可能性较小。除分期外，急诊入院是生存不良的最强决定因素。本研究中导致急诊入院的因素与诊断延迟相关的因素相似。发现的社会经济梯度表明，对公众患者进行患者教育并更早获得内镜检查可减少急诊表现。
