年龄对于接受放疗的不可手术Ⅲ期非小细胞肺癌患者的预后价值:基于监测、流行病学和最终结果数据库的竞争风险分析

Prognostic value of age in patients with inoperable stageⅢnon-small cell lung cancer after radiotherapy:a competing risk analysis based on the Surveillance,Epidemiology,and End Results database

目的:探讨监测、流行病学和最终结果(SEER)数据库中接受放疗的不可手术Ⅲ期非小细胞肺癌(NSCLC)患者数据,评估年龄对预后的意义。方法:收集SEER数据库中2010年至2016年经过美国癌症联合会(AJCC)第7版分期标准诊断为ⅢA和ⅢB期未接受手术治疗、接受放疗的NSCLC患者资料,共17117例纳入分析。根据最大选择检验确定年龄的最佳分界值为72岁,据此将患者分为年轻组(<72岁)(11008例)和年老组(≥72岁)(6109例)。比较两组的临床基本特征,采用Kaplan-Meier法进行总生存(OS)分析,并行log-rank检验。采用多因素Cox比例风险回归模型分析OS影响因素。采用累积发生函数(CIF)估算两组患者肺癌特异死亡率和其他原因死亡率,应用Fine-Gray竞争风险模型评价两组间死亡率差异,并对肺癌特异死亡影响因素进行分析。结果:年老组患者中鳞状细胞癌比例高于年轻组[51.1%(3123/6109)比46.8%(5154/11008),P<0.01],ⅢA期比例亦高于年轻组[67.4%(4120/6109)比60.1%(6615/11008),P<0.01];年老组接受化疗患者比例低于年轻组[69.2%(4226/6109)比88.6%(9748/11008),P<0.01]。年轻组患者的2年和5年OS率分别为39.2%和18.0%,年老组分别为32.4%和12.5%,两组OS差异有统计学意义(P<0.01)。多因素Cox回归分析显示,年龄、性别、人种、诊断年份、病理类型、T分期、N分期、未手术原因、化疗均为患者放疗后OS的独立影响因素(均P<0.05),其中年龄(≥72岁比<72岁)的HR=1.13(95%CI 1.09~1.18)(P<0.01)。年老组2年和5年的肺癌特异死亡累积发生率分别为60.3%和75.7%,高于年轻组的55.9%和74.0%,两组肺癌特异死亡累积发生率差异有统计学意义(P<0.01);年老组2年和5年的其他原因死亡累积发生率分别为7.3%和11.8%,高于年轻组的4.9%和8.0%,两组其他原因死亡差异有统计学意义(P<0.01)。根据竞争风险模型分析显示,年龄、性别、人种、诊断年份、病理类型、T分期、N分期、是否化疗均为影响不可手术Ⅲ期NSCLC患者接受放疗后肺癌特异死亡的独立影响因素,其中年龄(≥72岁比<72岁)的HR=1.07(95%CI 1.02~1.12)(P=0.002)。结论:年龄是不可手术Ⅲ期接受放疗的NSCLC患者独立预后影响因素。年老患者预后差,其肺癌特异死亡和其他原因死亡的风险均升高。

Objective To explore the data of patients with inoperable stageⅢnon-small cell lung cancer(NSCLC)after radiotherapy from the Surveillance,Epidemiology,and End Results(SEER)database,and to evaluate the effect of age on prognosis.Methods The data of patients with inoperable stageⅢA andⅢB NSCLC according to the 7th edition of the American Joint Committee on Cancer(AJCC)staging standard who had been treated with radiotherapy from 2010 to 2016 were collected in the SEER database.A total of 17117 cases were included in the analysis.According to the maximally selected test,the best cut-off value of age was 72 years old.According to the best cut-off value of age,patients were divided into the young group(<72 years old,11008 cases)and the elderly group(≥72 years old,6109 cases).The basic clinical characteristics were compared between the two groups.Kaplan-Meier method was used to analyze the overall survival(OS)and log-rank test was performed.The multivariate Cox proportional hazards regression model was used to analyze the influencing factors for OS.The cumulative incidence function(CIF)was used to calculate the lung cancer-specific death rate and death rate from other causes in the different age groups,and the difference between the two groups was compared by Fine-Gray competing risk model,and the influencing factors of lung cancer-specific death were analyzed.Results The proportion of squamous cell carcinoma in the elderly group was higher than that in the young group[51.1%(3123/6109)vs.46.8%(5154/11008),P<0.01],and the proportion of stageⅢA was also higher than that in the young group[67.4%(4120/6109)vs.60.1%(6615/11008),P<0.01];the proportion of patients receiving chemotherapy in the elderly group was lower than that in the young group[69.2%(4226/6109)vs.88.6%(9748/11008),P<0.01].The 2-year and 5-year OS rates of the young group were 39.2%and 18.0%,and the elderly group were 32.4%and 12.5%(both P<0.01).The multivariate Cox regression analysis showed that age,gender,race,year of diagnosis,pathological type,T stage,N stage,reason for non-operation and chemotherapy were independent influencing factors for patients'OS after radiotherapy,and among them,HR of age(≥72 years old vs.<72 years old)was 1.13(95%CI 1.09-1.18)(P<0.01).The 2-year and 5-year cumulative incidence rate of lung cancer-specific death in the elderly group were 60.3%and 75.7%,which were higher than the corresponding values of 55.9%and 74.0%in the young group,and the difference of cumulative incidence rate of lung cancer-specific death between the two groups was statistically significant(P<0.01).The 2-year and 5-year cumulative incidence rate of death from other causes in the elderly group were 7.3%and 11.8%,which were higher than the corresponding values of 4.9%and 8.0%in the young group,and the difference of death from other causes between the two groups was statistically significant(P<0.01).The competing risk model analysis showed that age,gender,race,year of diagnosis,pathological type,T stage,N stage,and with or without chemotherapy were independent influencing factors for lung cancer-specific death in patients with inoperable stageⅢNSCLC after radiotherapy,and among them,HR of age(≥72 years old vs.<72 years old)was 1.07(95%CI 1.02-1.12)(P=0.002).Conclusions Age is an independent prognostic factor for patients with inoperable stageⅢNSCLC after radiotherapy.The prognosis of elderly patients is poor,and they have high risks of lung cancer-specific death and death from other causes.