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急诊入院后30天内诊断为癌症的危险因素和预后影响（Lancet Oncol IF：41.3）
Background 背景 Greater understanding of international cancer survival differences is needed. We aimed to identify predictors and consequences of cancer diagnosis through emergency presentation in different international jurisdictions in six high-income countries. 需要更多地了解国际癌症生存差异。我们的目标是通过在六个高收入国家的不同国际管辖区的紧急报告，确定癌症诊断的预测因素和后果。 Methods 方法 Using a federated analysis model, in this cross-sectional population-based study, we analysed cancer registration and linked hospital admissions data from 14 jurisdictions in six countries (Australia, Canada, Denmark, New Zealand, Norway, and the UK), including patients with primary diagnosis of invasive oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer during study periods from Jan 1, 2012, to Dec 31, 2017. Data were collected on cancer site, age group, sex, year of diagnosis, and stage at diagnosis. Emergency presentation was defined as diagnosis of cancer within 30 days after an emergency hospital admission. Using logistic regression, we examined variables associated with emergency presentation and associations between emergency presentation and short-term mortality. We meta-analysed estimates across jurisdictions and explored jurisdiction-level associations between cancer survival and the percentage of patients diagnosed as emergencies. 使用联邦分析模型，在这个以人口为基础的横断面研究中，我们分析了来自六个国家(澳大利亚、加拿大、丹麦、新西兰、挪威和英国)的14个辖区的癌症登记和入院数据，包括2012年1月1日至2017年12月31日研究期间初步诊断为侵袭性食管癌、胃癌、结肠癌、直肠癌、肝癌、胰腺癌、肺癌或卵巢癌的患者。收集资料包括肿瘤部位、年龄组、性别、诊断年份和诊断分期。 急诊就诊被定义为在入院后30天内诊断出癌症。使用逻辑回归，我们研究了与紧急情况表现相关的变量以及紧急情况表现和短期死亡率之间的联系。我们荟萃分析了各辖区的评估数据，并探讨了癌症存活率与被诊断为急诊病人百分比之间的辖区级联系。 Findings 发现 In 857 068 patients across 14 jurisdictions, considering all of the eight cancer sites together, the percentage of diagnoses through emergency presentation ranged from 24·0% (9165 of 38 212 patients) to 42·5% (12 238 of 28 794 patients). There was consistently large variation in the percentage of emergency presentations by cancer site across jurisdictions. Pancreatic cancer diagnoses had the highest percentage of emergency presentations on average overall (46·1% [30 972 of 67 173 patients]), with the jurisdictional range being 34·1% (1083 of 3172 patients) to 60·4% (1317 of 2182 patients). Rectal cancer had the lowest percentage of emergency presentations on average overall (12·1% [10 051 of 83 325 patients]), with a jurisdictional range of 9·1% (403 of 4438 patients) to 19·8% (643 of 3247 patients). Across the jurisdictions, older age (ie, 75-84 years and 85 years or older, compared with younger patients) and advanced stage at diagnosis compared with non-advanced stage were consistently associated with increased emergency presentation risk, with the percentage of emergency presentations being highest in the oldest age group (85 years or older) for 110 (98%) of 112 jurisdiction-cancer site strata, and in the most advanced (distant spread) stage category for 98 (97%) of 101 jurisdiction-cancer site strata with available information. Across the jurisdictions, and despite heterogeneity in association size (I2=93%), emergency presenters consistently had substantially greater risk of 12-month mortality than non-emergency presenters (odds ratio >1·9 for 112 [100%] of 112 jurisdiction-cancer site strata, with the minimum lower bound of the related 95% CIs being 1·26). There were negative associations between jurisdiction-level percentage of emergency presentations and jurisdiction-level 1-year survival for colon, stomach, lung, liver, pancreatic, and ovarian cancer, with a 10% increase in percentage of emergency presentations in a jurisdiction being associated with a decrease in 1-year net survival of between 2·5% (95% CI 0·28-4·7) and 7·0% (1·2-13·0). 在14个司法管辖区的857068名患者中，综合考虑所有8个癌症部位，通过急诊诊断的百分比从24.0%(38212名患者中的9165名)到42.5%(28794名患者中的12238名)。在不同司法管辖区，按癌症部位分类的急诊报告的百分比一直存在很大差异。胰腺癌的平均急诊比例最高(46.1%[30972/67173])，管辖范围为34.1%(1083/3172)~60.4%(1317/2182)。 直肠癌的平均急诊比例最低(12.1%[10051/83325例])，管辖范围为9.1%(403/4438例)至19.8%(643/3247例)。在各个司法管辖区，年龄较大(即，与年轻患者相比，75-84岁和85岁或以上)和确诊时的晚期与非晚期相比，急诊表现的风险一直较高，112个辖区癌症部位层中110个(98%)的急诊表现百分比最高，101个辖区癌症部位层中98个(97%)的急诊表现百分比最高。在不同司法管辖区，尽管关联规模不同(I2=93%)，急诊呈现者持续12个月死亡的风险显著高于非急诊呈现者(112个辖区-癌症部位地层中112个[100%]的优势比>1.9，相关95%CI的最小下限为1.26)。在结肠癌、胃癌、肺癌、肝脏、胰腺癌和卵巢癌患者中，辖区一级急诊病例的百分比与辖区一级1年生存率呈负相关，一个辖区内急诊病例百分比增加10%与1年净生存率下降2.5%(95%可信区间0·28-4.7)至7.0%(1.2-13.0)相关。 Interpretation 解释 Internationally, notable proportions of patients with cancer are diagnosed through emergency presentation. Specific types of cancer, older age, and advanced stage at diagnosis are consistently associated with an increased risk of emergency presentation, which strongly predicts worse prognosis and probably contributes to international differences in cancer survival. Monitoring emergency presentations, and identifying and acting on contributing behavioural and health-care factors, is a global priority for cancer control. 在国际上，相当大比例的癌症患者是通过急诊确诊的。特定类型的癌症、年龄较大和确诊时处于晚期的癌症与急诊表现的风险增加一致，这强烈地预示着更差的预后，并可能导致癌症存活率的国际差异。监测紧急情况，确定有助于行为和保健的因素并采取行动，是癌症控制的全球优先事项。 |
