Gynecologic Oncology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
College of Epidemiology, The University of Iowa, Iowa City, Iowa, USA.
Int J Gynecol Cancer. 2022 Apr 4;32(4):540-546. doi: 10.1136/ijgc-2021-003096.
To determine if there is a difference in overall survival of patients with epithelial ovarian cancer in rural, urban, and metropolitan settings in the United States.
We performed a retrospective cohort study using 2004-2016 National Cancer Database (NCDB) data including high and low grade, stage I-IV disease. Bivariate analyses used Student's t-test for continuous variables and χ test for dichotomous variables. Kaplan-Meier curves estimated survival of patients based on location of residence, and univariate analyses using Cox proportional HR assessed survival based on baseline characteristics. Multivariate analysis was performed to account for significant covariates. Propensity score matching was used to validate the multivariate survival model. For all tests, p<0.05 was considered statistically significant.
A total of 111 627 patients were included with a mean age of 62.5 years for metroolitan (range 18-90), 64.0 years for rural (range 19-90) and 63.2 years for urban areas (range 18-90). Of all patients included, 94 290 were in a metropolitan area (counties >1 million population or 50 000-999 999), 15 386 were in an urban area (population of 10 000-49 999), and 1951 were in a rural area (non-metropolitan/non-core population). Univariate Cox proportional hazards models showed clinically significant differences in survival in patients from metropolitan, urban, and rural areas. Multivariate Cox proportional hazards models showed a clinically significant increase in HRs for patients in rural settings (HR 1.17; 95% CI 1.06 to 1.29). Increasing age and stage, non-insured status, non-white race, and comorbidity were also significant for poorer survival.
Patients with ovarian cancer who live in rural settings with small populations and greater distance to tertiary care centers have poorer survival. These differences hold after controlling for stage, age, and other significant risk factors related to poorer outcomes. To improve clinical outcomes, we need further studies to identify which of these factors are actionable.
在美国，比较农村、城市和大都市环境中上皮性卵巢癌患者的总生存率是否存在差异。
我们使用 2004-2016 年国家癌症数据库（NCDB）的数据进行了回顾性队列研究，包括高分级和低分级、I-IV 期疾病。使用学生 t 检验比较连续变量，使用卡方检验比较二分类变量。基于居住地，使用 Kaplan-Meier 曲线估计患者的生存情况，基于基线特征，使用 Cox 比例风险 HR 的单变量分析评估生存情况。进行多变量分析以解释显著的协变量。采用倾向评分匹配验证多变量生存模型。所有检验中，p<0.05 认为有统计学意义。
共纳入 111627 例患者，其中大都会地区（范围 18-90 岁）患者的平均年龄为 62.5 岁，农村地区（范围 19-90 岁）为 64.0 岁，城市地区（范围 18-90 岁）为 63.2 岁。在所有纳入的患者中，94290 例来自大都市地区（人口>100 万或 500000-999999），15386 例来自城市地区（人口 10000-49999），1951 例来自农村地区（非大都市/非核心地区）。单变量 Cox 比例风险模型显示，来自大都市、城市和农村地区的患者在生存方面存在显著的临床差异。多变量 Cox 比例风险模型显示，农村地区患者的 HR 显著升高（HR 1.17；95%CI 1.06-1.29）。年龄和分期增加、无保险状态、非白种人种族和合并症也是生存较差的显著因素。
居住在人口较少、距离三级治疗中心较远的农村地区的卵巢癌患者生存较差。在控制分期、年龄和其他与不良结局相关的显著危险因素后，这些差异仍然存在。为了改善临床结局，我们需要进一步研究确定哪些因素是可以改善的。
