Rajan Prabhakar, Sooriakumaran Prasanna, Nyberg Tommy, Akre Olof, Carlsson Stefan, Egevad Lars, Steineck Gunnar, Wiklund N Peter
Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden.
J Clin Oncol. 2017 Nov 1;35(31):3566-3574. doi: 10.1200/JCO.2016.70.7794. Epub 2017 Sep 20.
Purpose To determine the effect of comorbidity on prostate cancer (PCa)-specific mortality across treatment types. Patients and Methods These are the results of a population-based observational study in Sweden from 1998 to 2012 of 118,543 men who were diagnosed with PCa with a median follow-up of 8.3 years (interquartile range, 5.2 to 11.5 years) until death from PCa or other causes. Patients were categorized by patient characteristics (marital status, educational level) and tumor characteristics (serum prostate-specific antigen, tumor grade and clinical stage) and by treatment type (radical prostatectomy, radical radiotherapy, androgen deprivation therapy, and watchful waiting). Data were stratified by Charlson comorbidity index (0, 1, 2, or ≥ 3). Mortality from PCa and other causes and after stabilized inverse probability weighting adjustments for clinical patient and tumor characteristics and treatment type was determined. Kaplan-Meier estimates and Cox proportional hazards regression models were used to calculate hazard ratios. Results In the complete unadjusted data set, we observed an effect of increased comorbidity on PCa-specific and other-cause mortality. After adjustments for patient and tumor characteristics, the effect of comorbidity on PCa-specific mortality was lost but maintained for other-cause mortality. After additional adjustment for treatment type, we again failed to observe an effect for comorbidity on PCa-specific mortality, although it was maintained for other-cause mortality. Conclusion This large observational study suggests that comorbidity affects other cause-mortality but not PCa-specific- mortality after accounting for patient and tumor characteristics and treatment type. Regardless of radical treatment type (radical prostatectomy or radical radiotherapy), increasing comorbidity does not seem to significantly affect the risk of dying from PCa. Consequently, differences in oncologic outcomes that were observed in population-based comparative effectiveness studies of PCa treatments may not be a result of the varying distribution of comorbidity among treatment groups.
目的 确定合并症对不同治疗类型的前列腺癌（PCa）特异性死亡率的影响。
患者与方法 这是一项基于瑞典人群的观察性研究结果，研究对象为1998年至2012年期间被诊断为PCa的118,543名男性，中位随访时间为8.3年（四分位间距为5.2至11.5年），直至因PCa或其他原因死亡。患者按患者特征（婚姻状况、教育水平）、肿瘤特征（血清前列腺特异性抗原、肿瘤分级和临床分期）以及治疗类型（根治性前列腺切除术、根治性放疗、雄激素剥夺治疗和观察等待）进行分类。数据按Charlson合并症指数（0、1、2或≥3）分层。确定PCa和其他原因导致的死亡率以及在对临床患者、肿瘤特征和治疗类型进行稳定的逆概率加权调整后的死亡率。使用Kaplan-Meier估计值和Cox比例风险回归模型计算风险比。
结果 在完整的未调整数据集中，我们观察到合并症增加对PCa特异性死亡率和其他原因死亡率有影响。在对患者和肿瘤特征进行调整后，合并症对PCa特异性死亡率的影响消失，但对其他原因死亡率的影响仍然存在。在对治疗类型进行额外调整后，我们再次未观察到合并症对PCa特异性死亡率有影响，尽管对其他原因死亡率的影响仍然存在。
结论 这项大型观察性研究表明，在考虑患者和肿瘤特征以及治疗类型后，合并症影响其他原因死亡率，但不影响PCa特异性死亡率。无论根治性治疗类型（根治性前列腺切除术或根治性放疗）如何，合并症增加似乎不会显著影响死于PCa的风险。因此，在基于人群的PCa治疗比较有效性研究中观察到的肿瘤学结果差异可能不是治疗组之间合并症分布不同的结果。
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