Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.
Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut.
JAMA Netw Open. 2023 Jul 3;6(7):e2323115. doi: 10.1001/jamanetworkopen.2023.23115.
Improvements in cancer outcomes have led to a need to better understand long-term oncologic and nononcologic outcomes and quantify cancer-specific vs noncancer-specific mortality risks among long-term survivors.
To assess absolute and relative cancer-specific vs noncancer-specific mortality rates among long-term survivors of cancer, as well as associated risk factors.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 627 702 patients in the Surveillance, Epidemiology, and End Results cancer registry with breast, prostate, or colorectal cancer who received a diagnosis between January 1, 2003, and December 31, 2014, who received definitive treatment for localized disease and who were alive 5 years after their initial diagnosis (ie, long-term survivors of cancer). Statistical analysis was conducted from November 2022 to January 2023.
Survival time ratios (TRs) were calculated using accelerated failure time models, and the primary outcome of interest examined was death from index cancer vs alternative (nonindex cancer) mortality across breast, prostate, colon, and rectal cancer cohorts. Secondary outcomes included subgroup mortality in cancer-specific risk groups, categorized based on prognostic factors, and proportion of deaths due to cancer-specific vs noncancer-specific causes. Independent variables included age, sex, race and ethnicity, income, residence, stage, grade, estrogen receptor status, progesterone receptor status, prostate-specific antigen level, and Gleason score. Follow-up ended in 2019.
The study included 627 702 patients (mean [SD] age, 61.1 [12.3] years; 434 848 women [69.3%]): 364 230 with breast cancer, 118 839 with prostate cancer, and 144 633 with colorectal cancer who survived 5 years or more from an initial diagnosis of early-stage cancer. Factors associated with shorter median cancer-specific survival included stage III disease for breast cancer (TR, 0.54; 95% CI, 0.53-0.55) and colorectal cancer (colon: TR, 0.60; 95% CI, 0.58-0.62; rectal: TR, 0.71; 95% CI, 0.69-0.74), as well as a Gleason score of 8 or higher for prostate cancer (TR, 0.61; 95% CI, 0.58-0.63). For all cancer cohorts, patients at low risk had at least a 3-fold higher noncancer-specific mortality compared with cancer-specific mortality at 10 years of diagnosis. Patients at high risk had a higher cumulative incidence of cancer-specific mortality than noncancer-specific mortality in all cancer cohorts except prostate.
This study is the first to date to examine competing oncologic and nononcologic risks focusing on long-term adult survivors of cancer. Knowledge of the relative risks facing long-term survivors may help provide pragmatic guidance to patients and clinicians regarding the importance of ongoing primary and oncologic-focused care.
癌症治疗效果的改善使得人们需要更好地了解癌症患者的长期肿瘤学和非肿瘤学结果，并量化长期幸存者的癌症特异性和非癌症特异性死亡风险。
评估癌症长期幸存者的癌症特异性和非癌症特异性死亡率的绝对和相对比率，以及相关的风险因素。
设计、地点和参与者：这项队列研究纳入了美国监测、流行病学和最终结果癌症注册中心的 627702 名患有乳腺癌、前列腺癌或结直肠癌的患者，这些患者的诊断时间为 2003 年 1 月 1 日至 2014 年 12 月 31 日，接受了局部疾病的明确治疗，并且在初始诊断后 5 年仍存活（即癌症的长期幸存者）。统计分析于 2022 年 11 月至 2023 年 1 月进行。
使用加速失效时间模型计算生存时间比（TR），主要关注的结果是在乳腺癌、前列腺癌、结肠癌和直肠癌队列中，索引癌症与替代（非索引）死亡率之间的死亡情况。次要结果包括根据预后因素分类的癌症特异性风险组的亚组死亡率，以及因癌症特异性和非癌症特异性原因导致的死亡比例。自变量包括年龄、性别、种族和民族、收入、居住地、分期、分级、雌激素受体状态、孕激素受体状态、前列腺特异性抗原水平和 Gleason 评分。随访于 2019 年结束。
这项研究纳入了 627702 名患者（平均[标准差]年龄，61.1[12.3]岁；女性 434848 名[69.3%]）：364230 名患有乳腺癌，118839 名患有前列腺癌，144633 名患有结直肠癌，他们在初始诊断为早期癌症后至少存活 5 年。与中位癌症特异性生存率较短相关的因素包括乳腺癌的 III 期疾病（TR，0.54；95%CI，0.53-0.55）和结直肠癌（结肠癌：TR，0.60；95%CI，0.58-0.62；直肠癌：TR，0.71；95%CI，0.69-0.74），以及前列腺癌的 Gleason 评分 8 或更高（TR，0.61；95%CI，0.58-0.63）。对于所有癌症队列，低危患者在诊断后 10 年的非癌症特异性死亡率至少是癌症特异性死亡率的 3 倍。在所有癌症队列中，高危患者的癌症特异性死亡率比非癌症特异性死亡率的累积发生率都更高，除了前列腺癌。
这是迄今为止第一项针对癌症长期幸存者的肿瘤学和非肿瘤学风险的竞争研究。了解长期幸存者面临的相对风险，可能有助于为患者和临床医生提供有关持续进行初级和肿瘤学为重点的护理的重要性的实用指导。
