Harding M J, Paul J, Gillis C R, Kaye S B
Department of Medical Oncology, Beatson Oncology Centre, Western Infirmary, Glasgow, UK.
Lancet. 1993 Apr 17;341(8851):999-1002. doi: 10.1016/0140-6736(93)91082-w.
The causes of geographical differences in cancer survival among regions of the UK are unclear. Population-based audit of management of patients with non-seminomatous germ-cell tumours (NSGCT) in the west of Scotland enabled us to assess the relative contributions to outcome of recognised prognostic factors, treatment centre, and protocol treatment. Data on treatment and outcome were analysed for 440 (97%) of 454 men with NSGCT diagnosed between 1975 and 1989. All but 11 patients were treated at tertiary referral centres; 235 were treated at a single unit (unit 1) and 194 at four other units (2-5). 99 men have died, 89 (20%) from NSGCT. Independent prognostic factors for NSGCT survival were extent of tumour at diagnosis (p < 0.001), 5-year period of diagnosis (from 1975-79 to 1985-89, p < 0.001), and treatment unit (unit 1 vs units 2-5, p < 0.001). Unit 1, which had the best survival rates, treated most patients overall (53%), including the majority (70%) in the worst prognostic category (poor-prognosis metastatic disease). The proportion of men receiving nationally agreed protocol treatment was higher at unit 1 than elsewhere (97 vs 61%, p < 0.0001). However, analysis restricted to men who received protocol treatment, adjusted for other important prognostic variables, still showed a survival advantage for this unit (relative death rate units 2-5 vs unit 1, 2.82 [95% CI 1.53-5.19], p < 0.001). These findings suggest that centralisation of treatment for NSGCT improves outcome; the benefit seems to be additional to any advantage resulting from protocol treatment.
英国各地区癌症生存率存在地理差异的原因尚不清楚。对苏格兰西部非精原细胞瘤性生殖细胞肿瘤（NSGCT）患者的管理进行基于人群的审计，使我们能够评估公认的预后因素、治疗中心和方案治疗对预后的相对贡献。分析了1975年至1989年间确诊的454例NSGCT男性患者中440例（97%）的治疗和预后数据。除11例患者外，所有患者均在三级转诊中心接受治疗；235例在单个单位（单位1）接受治疗，194例在其他四个单位（2 - 5）接受治疗。99名男性已经死亡，其中89例（20%）死于NSGCT。NSGCT生存的独立预后因素为诊断时肿瘤的范围（p < 0.001）、诊断的5年时间段（从1975 - 79年到1985 - 89年，p < 0.001）以及治疗单位（单位1与单位2 - 5相比，p < 0.001）。单位1的生存率最高，总体治疗的患者最多（53%），包括预后最差类别（预后不良的转移性疾病）中的大多数（70%）。单位1接受全国商定方案治疗的男性比例高于其他地方（97%对61%，p < 0.0001）。然而，对接受方案治疗的男性进行分析，并对其他重要的预后变量进行调整后，仍显示该单位具有生存优势（单位2 - 5与单位1的相对死亡率，2.82 [95%可信区间1.53 - 5.19]，p < 0.001）。这些发现表明，NSGCT治疗的集中化可改善预后；这种益处似乎是方案治疗所带来的任何优势之外的额外优势。
