Goodwin J S, Samet J M, Hunt W C
Center on Aging, University of Texas Medical Branch, Galveston 77555-0460, USA.
J Natl Cancer Inst. 1996 Aug 7;88(15):1031-8. doi: 10.1093/jnci/88.15.1031.
We and others have previously described a number of characteristics that are associated with delays in diagnosis and increased risk for inadequate treatment of older women and men with cancer. These characteristics include poor social support, limited access to transportation, and impaired cognition. However, there is little information on how these factors influence survival of older cancer patients.
The purpose of the study was to determine which patient characteristics predicted survival up to 10 years after the diagnosis of cancer.
In 1984, we initiated a population-based study of men and women who were 65 years of age or older, living in a six-county area of New Mexico, and newly diagnosed with cancer. For 646 individuals with cancer of the breast (n = 188), prostate (n = 247), or colon or rectum (n = 211), we assessed patient baseline characteristics, disease stage at diagnosis, and adequacy of treatment (definitive or nondefinitive) as determinants of survival for up to 10 years following diagnosis. Multivariate survival models were used to analyze the data; all P values were two-sided.
In multivariate analyses, we first included all patient characteristics, except the stage at diagnosis and the adequacy of treatment. In this initial analysis, the following were among variables that were significantly associated with patient survival: age, education, cancer knowledge, ethnic group, and cognitive status. When stage at diagnosis and adequacy of treatment were added to the model, both advanced stage at diagnosis (hazard ratio = 1.7 [95% confidence interval ¿CI¿ = 1.3-2.1] for diagnosis at regional stage versus local stage; hazard ratio = 3.0 [95% CI = 2.0-4.7] for distant stage versus local stage) and inadequate treatment (hazard ratio = 1.6 [95% CI = 1.1-2.3]) were associated with poor survival. However, adding stage at diagnosis and adequacy of treatment to the analysis had little influence on the magnitude of the effect of patient characteristics on survival. In separate analyses of patient data by cancer site, receipt of nondefinitive therapy was associated with increased mortality among patients with colon/rectal cancer (hazard ratio = 7.8 [95% CI = 2.8-21.4]) and breast cancer (hazard ratio = 2.2 [95% CI = 1.1-4.3]) but not among patients with prostate cancer (hazard ratio = 1.0 [95% CI = 0.6-1.9]).
Advanced stage at diagnosis and inadequate treatment of older cancer patients are associated with poor survival. Impaired cognition and inadequate education in elderly patients are also associated with poor survival. This decreased survival does not appear to be a consequence of known barriers to health care that are responsible for delays in diagnosis and for inadequate treatment.
Efforts to facilitate early diagnosis and receipt of definitive treatment for cancer in older individuals may improve their survival.
我们及其他研究人员之前曾描述过一些与老年癌症患者诊断延迟及治疗不足风险增加相关的特征。这些特征包括社会支持不足、交通不便以及认知功能受损。然而，关于这些因素如何影响老年癌症患者的生存情况，相关信息却很少。
本研究的目的是确定哪些患者特征能够预测癌症诊断后长达10年的生存期。
1984年，我们启动了一项基于人群的研究，对象为年龄在65岁及以上、居住在新墨西哥州六个县区域且新诊断为癌症的男性和女性。对于646例患有乳腺癌（n = 188）、前列腺癌（n = 247）或结肠癌或直肠癌（n = 211）的患者，我们评估了患者的基线特征、诊断时的疾病分期以及治疗的充分性（确定性或非确定性），将其作为诊断后长达10年生存期的决定因素。使用多变量生存模型对数据进行分析；所有P值均为双侧。
在多变量分析中，我们首先纳入了所有患者特征，但不包括诊断时的分期和治疗的充分性。在这项初步分析中，以下因素与患者生存显著相关：年龄、教育程度、癌症知识、种族和认知状态。当将诊断时的分期和治疗的充分性纳入模型时，诊断时的晚期（区域分期诊断与局部分期相比，风险比 = 1.7 [95%置信区间（CI）= 1.3 - 2.1]；远处分期与局部分期相比，风险比 = 3.0 [95% CI = 2.0 - 4.7]）和治疗不足（风险比 = 1.6 [95% CI = 1.1 - 2.3]）均与生存不良相关。然而，将诊断时的分期和治疗的充分性纳入分析对患者特征对生存影响的大小影响不大。在按癌症部位对患者数据进行的单独分析中，接受非确定性治疗与结肠癌/直肠癌患者（风险比 = 7.8 [95% CI = 2.8 - 21.4]）和乳腺癌患者（风险比 = 2.2 [95% CI = 1.1 - 4.3]）的死亡率增加相关，但与前列腺癌患者无关（风险比 = 1.0 [95% CI = 0.6 - 1.9]）。
老年癌症患者诊断时的晚期和治疗不足与生存不良相关。老年患者认知功能受损和教育程度不足也与生存不良相关。这种生存下降似乎并非是导致诊断延迟和治疗不足的已知医疗保健障碍的结果。
促进老年个体癌症早期诊断并接受确定性治疗的努力可能会改善他们的生存情况。
