乳腺癌和肺癌全身抗癌治疗后的30天死亡率

　　2016年9月，英国《柳叶刀肿瘤学分册》正式发表英格兰公共卫生署、英国癌症研究中心、皇家自由医院、宁威尔医院与医学院、牛津大学、莱斯特大学、格伦菲尔德医院、利兹癌症研究与病理学研究所、圣詹姆斯大学医院、阿登布鲁克医院癌症中心、圣詹姆斯医院肿瘤研究所的人群观察研究报告，分析了英格兰乳腺癌和肺癌全身抗癌治疗后的30天死亡率。

　　该研究对2014年1月1日～12月31日接受过1次或者多次全身抗癌治疗的29112例乳腺癌患者和15545例非小细胞肺癌患者进行了分析，获得了其中28364例乳腺癌患者和15045例肺癌患者在治疗后30天内的死亡率，发现其中700例乳腺癌患者（2.47%）和1274例肺癌（8.47%）在接受全身抗癌治疗的30天内死亡。 

　　治愈性全身抗癌治疗的30天死亡率：乳腺癌为0.26%（41/15626），肺癌为2.88%（70/2429），低于总体死亡率（乳腺癌2.47%，肺癌8.47%）。

　　姑息性全身抗癌治疗的30天死亡率，乳腺癌为7.48%（569/7602），肺癌为10.02%（1061/10587），高于总体死亡率（乳腺癌2.47%，肺癌8.47%）。

　　对其中23228例乳腺癌患者和9634例非小细胞肺癌患者进行回归分析，发现：

　　治愈性全身抗癌治疗的30天死亡率随着年龄增长而显著增加（乳腺癌比值比：1.085，99%置信区间：1.040～1.132，P＜0.0001；非小细胞肺癌比值比：1.045，99%置信区间：1.013～1.079，P=0.00033）。

　　姑息性全身抗癌治疗的30天死亡率随着年龄增长而显著减少（乳腺癌比值比：0.987，99%置信区间：0.977～0.996，P=0.00034；非小细胞肺癌比值比：0.987，99%置信区间：0.976～0.998，P=0.0015）。

　　首次与再次接受全身抗癌治疗的患者相比，全身抗癌治疗的30天死亡率显著增加（乳腺癌姑息性治疗、非小细胞肺癌治愈性治疗和姑息性治疗的比值比分别为2.326、3.371和2.667，99%置信区间分别为1.634～3.312、1.554～7.316和2.109～3.373；P均＜0.0001）。

　　一般健康状态较差（体力状态评分：2～4）与较好（体力状态评分：0）的患者相比，全身抗癌治疗的30天死亡率显著增加（乳腺癌治愈性治疗、姑息性治疗、非小细胞肺癌姑息性治疗的比值比分别为6.057、6.241、3.384，99%置信区间分别为1.333～27.513、4.180～9.319、2.276～5.032，P分别为0.0021、＜0.0001、＜0.0001）。

Lancet Oncol. 2016 Sep;17(9):1203-1216.

30-day mortality after systemic anticancer treatment for breast and lung cancer in England: a population-based, observational study.

Michael Wallington, Emma B Saxon, Martine Bomb, Rebecca Smittenaar, Matthew Wickenden, Sean McPhail, Jem Rashbass, David Chao, John Dewar, Denis Talbot, Michael Peake, Timothy Perren, Charles Wilson, David Dodwell.

Public Health England, London, UK; Cancer Research UK, London, UK; Royal Free Hospital, London, UK; Ninewells Hospital & Medical School, Dundee, UK; University of Oxford, Oxford, UK; University of Leicester, Glenfield Hospital, Leicester, UK; Leeds Institute of Cancer Research and Pathology, St James's University Hospital, Leeds, UK; Oncology Centre, Addenbrooke's NHS Trust, Cambridge, UK; Institute of Oncology, St James's Hospital, Leeds, UK.

Background: 30-day mortality might be a useful indicator of avoidable harm to patients from systemic anticancer treatments, but data for this indicator are limited. The Systemic Anti-Cancer Therapy (SACT) dataset collated by Public Health England allows the assessment of factors affecting 30-day mortality in a national patient population. The aim of this first study based on the SACT dataset was to establish national 30-day mortality benchmarks for breast and lung cancer patients receiving SACT in England, and to start to identify where patient care could be improved.

Methods: In this population-based study, we included all women with breast cancer and all men and women with lung cancer residing in England, who were 24 years or older and who started a cycle of SACT in 2014 irrespective of the number of previous treatment cycles or programmes, and irrespective of their position within the disease trajectory. We calculated 30-day mortality after the most recent cycle of SACT for those patients. We did logistic regression analyses, adjusting for relevant factors, to examine whether patient, tumour, or treatment-related factors were associated with the risk of 30-day mortality. For each cancer type and intent, we calculated 30-day mortality rates and patient volume at the hospital trust level, and contrasted these in a funnel plot.

Findings: Between Jan 1, and Dec, 31, 2014, we included 23,228 patients with breast cancer and 9634 patients with non-small cell lung cancer (NSCLC) in our regression and trust-level analyses. 30-day mortality increased with age for both patients with breast cancer and patients with NSCLC treated with curative intent, and decreased with age for patients receiving palliative SACT (breast curative: odds ratio [OR] 1.085, 99% CI 1.040-1.132; p<0.0001; NSCLC curative: 1.045, 1.013-1.079; p=0.00033; breast palliative: 0.987, 0.977-0.996; p=0.00034; NSCLC palliative: 0.987, 0.976-0.998; p=0.0015). 30-day mortality was also significantly higher for patients receiving their first reported curative or palliative SACT versus those who received SACT previously (breast palliative: OR 2.326 99% CI 1.634-3.312; p<0.0001; NSCLC curative: 3.371, 1.554-7.316; p<0.0001; NSCLC palliative: 2.667, 2.109-3.373; p<0.0001), and for patients with worse general wellbeing (performance status 2-4) versus those who were generally well (breast curative: 6.057, 1.333-27.513; p=0.0021; breast palliative: 6.241, 4.180-9.319; p<0.0001; NSCLC palliative: 3.384, 2.276-5.032; p<0.0001). We identified trusts with mortality rates in excess of the 95% control limits; this included seven for curative breast cancer, four for palliative breast cancer, five for curative NSCLC, and seven for palliative NSCLC.

Interpretation: Our findings show that several factors affect the risk of early mortality of breast and lung cancer patients in England and that some groups are at a substantially increased risk of 30-day mortality. The identification of hospitals with significantly higher 30-day mortality rates should promote review of clinical decision making in these hospitals. Furthermore, our results highlight the importance of collecting routine data beyond clinical trials to better understand the factors placing patients at higher risk of 30-day mortality, and ultimately improve clinical decision making. Our insights into the factors affecting risk of 30-day mortality will help treating clinicians and their patients predict the balance of harms and benefits associated with SACT.

Funding: Public Health England.

DOI: 10.1016/S1470-2045(16)30383-7