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十年大数据分析发现医疗保险对中青年女性早期乳腺癌死亡影响最大

2017-10-17 临床肿瘤学杂志 SIBCS


  20世纪80年代之前,美国白人女性的乳腺癌死亡率一直高于黑人女性。之后,情况出现逆转,并且差距不断扩大。2014年,黑人女性的乳腺癌死亡率比白人女性高41%,具体影响因素尚不明确。


  2017年10月16日,美国临床肿瘤学会《临床肿瘤学杂志》在线发表美国癌症学会、亚特兰大埃默里大学、波士顿达纳法伯癌症研究所的研究报告,分析了人口特征、合并共病、医疗保险、肿瘤特征、治疗方案对中青年女性早期乳腺癌全因死亡率的影响。


  该研究从全国癌症数据库找出2004~2013年被诊断为I~III期原发浸润乳腺癌、年龄为18~64岁的女性56万3497例,其中黑人7万8737例、白人48万4760例,中位年龄53岁,中位随访4.9年。按激素受体状态,依次根据各个变量(人口特征、合并共病、医疗保险、肿瘤特征、治疗方案)进行倾向评分优化匹配模型分层,使用多变量风险比,分析全因死亡超额相对风险。


倾向评分匹配:处理观察研究数据的统计学方法。在观察研究中,由于种种原因,数据偏差和混杂变量较多,倾向评分匹配正是为了减少这些偏差和混杂变量的影响,以便对研究组和对照组进行更合理的比较。这种方法一般常用于医学、公共卫生、经济学等领域。以公共卫生为例,假设研究问题是吸烟对于大众健康的影响,研究者常常得到的数据是观察研究数据,而不是随机对照研究数据,因为吸烟者的行为和结果,以及不吸烟者的行为和结果,是很容易观察到的。但是如果要进行随机对照研究,招收大量受试者,随机分配到吸烟组和不吸烟组,这种研究设计不太容易实现,也并不符合科研伦理,这种情况下观察研究是最合适的研究方法。但是面对最容易获得的观察研究数据,如果不加校正,很容易获得错误的结论,比如拿吸烟组健康状况最好的一些人和不吸烟组健康状况最不好的一些人作对比,得出吸烟对于健康并无负面影响的结论。从统计学角度分析原因,这是因为观察研究并未采用随机分组的方法,无法基于大数定理的作用,在研究组和对照组之间削弱混杂变量的影响,很容易产生系统偏差。倾向评分匹配就是用来解决这个问题,消除组别之间的干扰因素。


  结果发现,激素受体阳性乳腺癌女性占所有患者的78.5%,根据以下变量进行倾向评分优化匹配模型分层,其中黑人与白人女性相比,全因死亡风险比依次为:

  • 人口特征:2.05(95%CI:1.94~2.17)

  • 合并共病:1.93(95%CI:1.83~2.04)

  • 医疗保险:1.54(95%CI:1.47~1.62)

  • 肿瘤特征:1.30(95%CI:1.24~1.36)

  • 治疗方案:1.25(95%CI:1.19~1.31)


  对于黑人患者,上述影响因素合计全因死亡超额相对风险的76.3%,其中:

  • 医疗保险:37.0%

  • 肿瘤特征:23.2%

  • 合并共病:11.3%

  • 治疗方案:4.8%


  虽然激素受体阴性乳腺癌女性的全因死亡超额相对风险比显著较小,但是结果总体相似。


  因此,中青年女性黑人与白人相比,死亡风险较高。其中,医疗保险因素影响占三分之一以上,肿瘤特征因素影响不到五分之一。加强医疗服务的平等化,可以大大减少中青年女性乳腺癌整体生存的种族差异。


J Clin Oncol. 2017 Oct 16. [Epub ahead of print]


Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013.


Jemal A, Robbins AS, Lin CC, Flanders WD, DeSantis CE, Ward EM, Freedman RA.


American Cancer Society; Emory University, Atlanta, GA; Dana-Farber Cancer Institute, Boston, MA.


PURPOSE: To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer.


PATIENTS AND METHODS: Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs).


RESULTS: We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor-positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor-negative disease, although the HRs were substantially smaller.


CONCLUSION: Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.


PMID: 29035645


DOI: 10.1200/JCO.2017.73.7932





















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