All-Cause and Cancer-Specific Death of Older Adults Following Surgery for Cancer
All-Cause and Cancer-Specific Death of Older Adults Following Surgery for Cancer
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DOI：
10.1001/jamasurg.2021.1425
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发表时间：
2021-05-12
期刊：
影响因子：
16.9
通讯作者：
Hallet, Julie
中科院分区：
文献类型：
--
作者：
Chesney, Tyler R.;Coburn, Natalie;Hallet, Julie
重要性：老年人的癌症护理具有固有的复杂性，包括平衡癌症和非癌症死亡的风险。对病因特异性结果了解不足可能导致过度治疗和治疗不足。目的研究老年人癌症切除后5年内的全因死亡和癌症特异性死亡。设计、环境和参与者本基于人群的队列研究在加拿大安大略省进行，使用存储在ICES（前身为临床评估科学研究所）的管理数据库。所有在2007年1月1日至2017年12月31日期间因新诊断为癌症而接受手术切除的70岁或以上的成年人都被纳入研究。随访至2018年12月31日最后一次接触者死亡或审查。癌症切除。使用竞争风险方法，估计癌症和非癌症死亡的累积发生率，并根据重要的预后因素进行分层。采用多变量亚分布风险模型探讨预后因素。结果：82037例接受手术的老年人（年龄均大于70岁；52119例（63.5%）为女性）中，34044例死亡中有16900例（49.6%）与癌症相关，随访时间中位数为46（23-80）个月。在所有患者中，5年估计累积癌症死亡率（20.7%,95% CI, 20.4%-21.0%）超过非癌症死亡率（16.5%,95% CI, 16.2%-16.8%）。然而，在乳腺癌、前列腺癌和黑色素瘤皮肤癌、年龄超过85岁的患者和身体虚弱的患者中，非癌症死亡人数超过了手术后3年的癌症死亡人数。癌症类型、高龄和虚弱与死因特异性死亡独立相关。结论和相关性在人群水平上，选择手术的老年人癌症死亡的相对负担超过了非癌症死亡。没有哪个亚组在术后早期有更高的非癌性死亡负担，即使在更脆弱的患者中也是如此。这种病因特异性的总体预后信息应用于患者咨询，在系统层面评估老年癌症患者治疗过度或治疗不足的模式，并指导系统层面改进的目标，以完善老年癌症患者的选择标准和围手术期护理途径。
IMPORTANCE Cancer care has inherent complexities in older adults, including balancing risks of cancer and noncancer death. A poor understanding of cause-specific outcomes may lead to overtreatment and undertreatment.OBJECTIVE To examine all-cause and cancer-specific death throughout 5 years for older adults after cancer resection.DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). All adults 70 years or older who underwent resection for a new diagnosis of cancer between January 1, 2007, and December 31, 2017, were included. Patients were followed up until death or censored at date of last contact of December 31, 2018.EXPOSURES Cancer resection.MAIN OUTCOME AND MEASURES Using a competing risks approach, the cumulative incidence of cancer and noncancer death was estimated and stratified by important prognostic factors. Multivariable subdistribution hazard models were fit to explore prognostic factors.RESULTS Of 82 037 older adults who underwent surgery (all older than 70 years; 52 119 [63.5%] female), 16 900 of 34 044 deaths (49.6%) were cancer related at a median (interquartile range) follow-up of 46 (23-80) months. At 5 years, estimated cumulative incidence of cancer death (20.7%; 95% CI, 20.4%-21.0%) exceeded noncancer death (16.5%; 95% CI, 16.2%-16.8%) among all patients. However, noncancer deaths exceeded cancer deaths starting at 3 years after surgery in breast, prostate, and melanoma skin cancers, patients older than 85 years, and those with frailty. Cancer type, advancing age, and frailty were independently associated with cause-specific death.CONCLUSIONS AND RELEVANCE At the population level, the relative burden of cancer deaths exceeds noncancer deaths for older adults selected for surgery. No subgroup had a higher burden of noncancer death early after surgery, even in more vulnerable patients. This cause-specific overall prognosis information should be used for patient counseling, to assess patterns of over- or undertreatment in older adults with cancer at the system level, and to guide targets for system-level improvements to refine selection criteria and perioperative care pathways for older adults with cancer.