丹麦、英国、挪威和瑞典的结直肠癌的外科治疗和生存情况：一项基于人群的研究。
Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study.
机构信息
Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
出版信息
Lancet Oncol. 2019 Jan;20(1):74-87. doi: 10.1016/S1470-2045(18)30646-6. Epub 2018 Dec 10.
BACKGROUND
Survival from colorectal cancer has been shown to be lower in Denmark and England than in comparable high-income countries. We used data from national colorectal cancer registries to assess whether differences in the proportion of patients receiving resectional surgery could contribute to international differences in colorectal cancer survival.
METHODS
In this population-based study, we collected data from all patients aged 18-99 years diagnosed with primary, invasive, colorectal adenocarcinoma from Jan 1, 2010, to Dec 31, 2012, in Denmark, England, Norway, and Sweden, from national colorectal cancer registries. We estimated age-standardised net survival using multivariable modelling, and we compared the proportion of patients receiving resectional surgery by stage and age. We used logistic regression to predict the resectional surgery status patients would have had if they had been treated as in the best performing country, given their individual characteristics.
FINDINGS
We extracted registry data for 139 457 adult patients with invasive colorectal adenocarcinoma: 12 958 patients in Denmark, 97 466 in England, 11 450 in Norway, and 17 583 in Sweden. 3-year colon cancer survival was lower in England (63·9%, 95% CI 63·5-64·3) and Denmark (65·7%, 64·7-66·8) than in Norway (69·5%, 68·4-70·5) and Sweden (72·1%, 71·2-73·0). Rectal cancer survival was lower in England (69·7%, 69·1-70·3) than in the other three countries (Denmark 72·5%, 71·1-74·0; Sweden 74·1%, 72·7-75·4; and Norway 75·0%, 73·1-76·8). We found no significant differences in survival for patients with stage I disease in any of the four countries. 3-year survival after stage II or III rectal cancer and stage IV colon cancer was consistently lower in England (stage II rectal cancer 86·4%, 95% CI 85·0-87·6; stage III rectal cancer 75·5%, 74·2-76·7; and stage IV colon cancer 20·5%, 19·9-21·1) than in Norway (94·1%, 91·5-96·0; 83·4%, 80·1-86·1; and 33·0%, 31·0-35·1) and Sweden (92·9%, 90·8-94·6; 80·6%, 78·2-82·7; and 23·7%, 22·0-25·3). 3-year survival after stage II rectal cancer and stage IV colon cancer was also lower in England than in Denmark (stage II rectal cancer 91·2%, 88·8-93·1; and stage IV colon cancer 23·5%, 21·9-25·1). The total proportion of patients treated with resectional surgery ranged from 47 803 (68·4%) of 69 867 patients in England to 9582 (81·3%) of 11 786 in Sweden for colon cancer, and from 16 544 (59·9%) of 27 599 in England to 4106 (70·8%) of 5797 in Sweden for rectal cancer. This range was widest for patients older than 75 years (colon cancer 19 078 [59·7%] of 31 946 patients in England to 4429 [80·9%] of 5474 in Sweden; rectal cancer 4663 [45·7%] of 10 195 in England to 1342 [61·9%] of 2169 in Sweden), and the proportion of patients treated with resectional surgery was consistently lowest in England. The age gradient of the decline in the proportion of patients treated with resectional surgery was steeper in England than in the other three countries in all stage categories. In the hypothetical scenario where all patients were treated as in Sweden, given their age, sex, and disease stage, the largest increase in resectional surgery would be for patients with stage III rectal cancer in England (increasing from 70·3% to 88·2%).
INTERPRETATION
Survival from colon cancer and rectal cancer in England and colon cancer in Denmark was lower than in Norway and Sweden. Survival paralleled the relative provision of resectional surgery in these countries. Differences in patient selection for surgery, especially in patients older than 75 years or individuals with advanced disease, might partly explain these differences in international colorectal cancer survival.
FUNDING
Early Diagnosis Policy Research Grant from Cancer Research UK (C7923/A18348).
背景
丹麦和英国的结直肠癌患者生存率低于可比的高收入国家。我们使用国家结直肠癌登记处的数据，评估接受切除术的患者比例差异是否会导致结直肠癌生存率的国际差异。
方法
在这项基于人群的研究中，我们从丹麦、英格兰、挪威和瑞典的国家结直肠癌登记处收集了 2010 年 1 月 1 日至 2012 年 12 月 31 日期间年龄在 18-99 岁之间诊断为原发性、侵袭性结直肠腺癌的所有患者的数据。我们使用多变量模型估计了年龄标准化的净生存率，并比较了各期和各年龄组接受切除术的患者比例。我们使用逻辑回归预测了如果患者按照最佳治疗国家的标准进行治疗，他们会接受切除术的情况，这取决于他们的个体特征。
结果
我们从 139457 例成年侵袭性结直肠腺癌患者的登记处数据中提取了数据：丹麦 12958 例，英格兰 97466 例，挪威 11450 例，瑞典 17583 例。英格兰（63.9%，95%CI 63.5-64.3）和丹麦（65.7%，64.7-66.8）的 3 年结肠癌生存率低于挪威（69.5%，68.4-70.5）和瑞典（72.1%，71.2-73.0）。英格兰（69.7%，69.1-70.3）的直肠癌生存率低于其他三个国家（丹麦 72.5%，71.1-74.0；瑞典 74.1%，72.7-75.4；挪威 75.0%，73.1-76.8）。我们在四个国家中都没有发现 I 期疾病患者的生存率有显著差异。在 II 期或 III 期直肠癌和 IV 期结肠癌患者中，3 年生存率在英格兰一直较低（II 期直肠癌 86.4%，95%CI 85.0-87.6；III 期直肠癌 75.5%，74.2-76.7；IV 期结肠癌 20.5%，19.9-21.1），低于挪威（94.1%，91.5-96.0；83.4%，80.1-86.1；33.0%，31.0-35.1）和瑞典（92.9%，90.8-94.6；80.6%，78.2-82.7；23.7%，22.0-25.3）。英格兰 II 期直肠癌和 IV 期结肠癌患者的 3 年生存率也低于丹麦（II 期直肠癌 91.2%，88.8-93.1；IV 期结肠癌 23.5%，21.9-25.1）。接受切除术治疗的患者比例从英格兰的 69867 例患者中接受切除术治疗的 68438 例（68.4%）到瑞典的 11786 例患者中接受切除术治疗的 9582 例（81.3%）不等，从英格兰的 27599 例患者中接受切除术治疗的 16544 例（59.9%）到瑞典的 5797 例患者中接受切除术治疗的 4106 例（70.8%）不等。这一范围在年龄超过 75 岁的患者中最为广泛（英格兰 31946 例患者中接受切除术治疗的 19078 例（59.7%）到瑞典 5474 例患者中接受切除术治疗的 4429 例（80.9%）；英格兰 10195 例患者中接受切除术治疗的 4663 例（45.7%）到瑞典 2169 例患者中接受切除术治疗的 1342 例（61.9%）），且接受切除术治疗的患者比例在英格兰一直最低。在所有分期类别中，英格兰接受切除术治疗的患者比例下降的年龄梯度比其他三个国家都要陡峭。在假设所有患者都按照瑞典的标准接受治疗的情况下，考虑到他们的年龄、性别和疾病分期，接受切除术治疗的患者数量增幅最大的是英格兰的 III 期直肠癌患者（从 70.3%增加到 88.2%）。
结论
英格兰和丹麦的结肠癌和直肠癌生存率以及英格兰的结肠癌生存率均低于挪威和瑞典。生存率与这些国家提供切除术的相对情况相符。手术患者选择的差异，特别是年龄在 75 岁以上或患有晚期疾病的患者，可能部分解释了国际结直肠癌生存率的差异。
资助
英国癌症研究中心（C7923/A18348）早期诊断政策研究拨款。
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