乳腺癌流行病學及伴隨疾病現(xiàn)狀

乳腺癌流行病學及伴隨疾病現(xiàn)狀乳腺癌流行病學及伴隨疾病現(xiàn)狀女性癌癥發(fā)病和死亡：發(fā)達國家vs中國順位發(fā)病死亡發(fā)達國家中國發(fā)達國家中國1乳腺（27.9%）肺肺肺2結(jié)直腸乳腺（15.1%）乳腺（15.4%）胃3肺胃結(jié)直腸肝4子宮體結(jié)直腸胰腺結(jié)直腸5卵巢肝胃食管6胃子宮體卵巢乳腺（6.2%）7甲狀腺食管肝子宮體8胰腺子宮頸白血病胰腺9皮膚黑色素瘤甲狀腺子宮頸膀胱10NHL卵巢子宮體白血病Globocan2012第2頁，共32頁幻燈片。女性癌癥發(fā)病和死亡：發(fā)達國家vs中國順位發(fā)病死亡發(fā)達國家中國2015癌癥估計第3頁，共32頁幻燈片。中國2015癌癥估計第3頁，共32頁幻燈片。全球女性乳腺癌發(fā)病、死亡時間趨勢全球乳腺癌發(fā)病的差異逐步縮小第4頁，共32頁幻燈片。全球女性乳腺癌發(fā)病、死亡時間趨勢全球乳腺癌發(fā)病的差異逐步縮小2004-2008年診斷的20272例上海戶籍乳腺癌患者 5年觀察生存率81.64% 5年相對生存率91.81%Concord-3的中美乳腺癌生存資料第5頁，共32頁幻燈片。2004-2008年診斷的20272例上海戶籍乳腺癌患者 CONCORD-3研究顯示乳腺癌目前依舊是全世界發(fā)生率最高的女性腫瘤，而在全球數(shù)據(jù)中僅登記了中國大陸53791例（美國登記159976例），對于中國的數(shù)據(jù)登記完整度與認識是不足的。我們需要進一步認識中國乳腺癌的特殊性。中國乳腺癌生存資料仍不足第6頁，共32頁幻燈片。CONCORD-3研究顯示乳腺癌目前依舊是全世界發(fā)生率最高的中國乳腺癌生存的城鄉(xiāng)差異第7頁，共32頁幻燈片。中國乳腺癌生存的城鄉(xiāng)差異第7頁，共32頁幻燈片。乳腺癌患者的10年生存StageNo.ofpatientsNo.ofevents5-Yearsurvivalrate(%)10-Yearsurvivalrate(%)012,28526698.395.4I39,2841,55796.692.7II40,0243,95191.884.8III13,7746,54475.863.4IV1,6191,02934.022.2Unknown2,998343--Total109,98810,69091.284.8Stage-specific5-and10-yearoverallsurvivalrates(2001–2012,KoreanBreastCancerSocietyregistrydata)JBreastCancer.2017Mar;20(1):1–11.Publishedonline2017Mar24.doi:

10.4048/jbc.2017.20.1.1PMCID:PMC5378568BasicFactsofBreastCancerinKoreain2014:The10-YearOverallSurvivalProgressEunHwaPark,SunYoungMin,1

ZisunKim,2

ChanSeokYoon,3

Kyu-WonJung,4

SeokJinNam,5

SeJeongOh,6

SeeyounLee,7

Byeong-WooPark,8

WoosungLim,9

MinHeeHur,10andKoreanBreastCancerSociety美國乳腺癌10年生存率SEER資料1973年診斷61%1993年診斷83%中國乳腺癌10年生存率上海隊列資料觀察生存率80.5%無病生存率78.8%第8頁，共32頁幻燈片。乳腺癌患者的10年生存StageNo.ofpatientOncologist.2015Sep;20(9):1044-50.doi:10.1634/theoncologist.2014-0290.Epub2015Aug3.BreastCancerDisparities:AMulticenterComparisonofTumorDiagnosis,Characteristics,andSurgicalTreatmentinChinaandtheU.S.中國醫(yī)生遇到的是更復(fù)雜的患者…中國乳腺癌與美國不一樣

更年輕，瘤體更大，淋巴結(jié)陽性更多，分期更晚第9頁，共32頁幻燈片。Oncologist.2015Sep;20(9):104上海女性乳腺癌發(fā)病年齡分布的時間趨勢<4545- 50- 55-60->6510%10%20%20%10%30%第10頁，共32頁幻燈片。上海女性乳腺癌發(fā)病年齡分布的時間趨勢<45在上海、北京、天津、廣州等發(fā)達地區(qū)乳腺癌的診治與生存與美國看齊AllemaniC,etal.Lancet.2018Jan30.pii:S0140-6736(17)33326-3.CACANCERJCLIN2016;66:115–132.乳腺癌：基礎(chǔ)與臨床的轉(zhuǎn)化83.2%中國女性乳腺癌5年生存估計90.2%美國5年生存率7.3%2004-2014十年生存率變化3.9%發(fā)病率年度變化年新發(fā)乳腺癌人數(shù)27萬+年新發(fā)病人數(shù)超過美國，世界最多1.1%死亡率年度變化VS.中國乳腺癌患者數(shù)量增長，需求增長第11頁，共32頁幻燈片。在上海、北京、天津、廣州等發(fā)達地區(qū)乳腺癌的診治與生存與美國看乳腺癌預(yù)防的目標減少新發(fā)病例推遲發(fā)病年齡降低死亡風險第12頁，共32頁幻燈片。乳腺癌預(yù)防的目標減少新發(fā)病例推遲發(fā)病年齡降低死亡風險第12頁對乳腺癌預(yù)后的認識轉(zhuǎn)變13預(yù)后轉(zhuǎn)移復(fù)發(fā)生活質(zhì)量抑郁認知……并發(fā)疾病第二原發(fā)腫瘤死亡癌癥死亡非癌癥死亡其他疾病的競爭死亡生存時間延長診斷時年齡后移第13頁，共32頁幻燈片。對乳腺癌預(yù)后的認識轉(zhuǎn)變15預(yù)后轉(zhuǎn)移復(fù)發(fā)生活質(zhì)量抑郁認知……并治療依從性治療規(guī)范性復(fù)發(fā)轉(zhuǎn)移伴隨疾病生活方式乳腺癌長期預(yù)后的影響因素第14頁，共32頁幻燈片。治療治療復(fù)發(fā)伴隨疾病生活方式乳腺癌長期預(yù)后的影響因素第14頁乳腺癌患者的管理目標早期治愈，提升生存，促進生活質(zhì)量。乳腺癌患者全方位生存提升促進乳腺癌規(guī)范治療提升乳腺癌依從性及伴隨疾病管理促進飲食及生活方式改變第15頁，共32頁幻燈片。乳腺癌患者的管理目標早期治愈，提升生存，促進生活質(zhì)量。乳腺癌存在慢性病發(fā)疾病影響癌癥的發(fā)生風險發(fā)表在BMJ上面的就研究了1996年到2007年來自寶島臺灣共計405?878人的數(shù)據(jù)，進行隨訪分析之后，得出了8種影響癌癥發(fā)生的獨立慢性疾病因素BMJ2018;360:k134慢性疾病和標志物以及癌癥發(fā)生的風險第16頁，共32頁幻燈片。存在慢性病發(fā)疾病影響癌癥的發(fā)生風險發(fā)表在BMJ上面的就研究了慢性疾病和標志物與癌癥死亡率的風險具有統(tǒng)計學顯著相關(guān)性，并且這些關(guān)聯(lián)性通常比癌癥發(fā)病率更強BMJ2018;360:k134存在慢性病發(fā)疾病影響癌癥患者死亡風險第17頁，共32頁幻燈片。慢性疾病和標志物與癌癥死亡率的風險具有統(tǒng)計學顯著相關(guān)性，并且相關(guān)研究StudyTypeYearofPublicComorbidityBCmortalitytotalmortailtyLand,Review2012CharlsonComorbidityScore+LACECohort+Yancik2001stroke+asthma+diabetes+hypertension-PatnaikSEER201213specificcomorbidcondition+PatnaikSEER2012diabetes++CVD++LouwmanNetherlands2005diabetes+Janssen-Heijnen2007CVD+hypertensionnullnullWHELdiabetes++osteoporosis-第18頁，共32頁幻燈片。相關(guān)研究StudyTypeYearofPublicCom并發(fā)疾病與乳腺癌生存：來自上海的研究報告分析包括2002-2006年期間被診斷患有I-III期乳腺癌20-75歲的4664名婦女，研究調(diào)查了主要合并癥與乳腺癌預(yù)后的關(guān)系BreastCancerResTreat.2013May;139(1):227–235.第19頁，共32頁幻燈片。并發(fā)疾病與乳腺癌生存：來自上海的研究報告分析包括2002-NHypertensionDiabetesCHDStrokeChronicGastritisn%n%n%n%n%Ageatdiagnosis,y

<502,0931728.2391.930.1430.1422610.8

50–591,37230622.3624.5433.1161.222616.5

≥601,19956747.3a18715.6a18615.5a826.8a21718.1aTNMstageb

I1,62236022.2875.4845.2342.128217.4

II2,39453022.11476.11134.7482.030512.7

III44511024.7378.3a235.2132.94911.0aER/PRstatusb

ER+/PR+2,37953722.61476.21154.8562.434414.5

ER+/PR?61616827.3437.0386.2162.68614.0

ER?/PR+3516217.7133.7113.151.45014.3

ER?/PR?1,30426920.6a836.4675.1221.718914.5BMI(kg/m2)

<25.03,04748616.01555.11103.6521.746015.1

25.0–29.991,36242631.31138.3926.8423.218413.5

≥3025513352.2a207.8a3011.8a72.7a259.7aaPvalue<0.05basedonChisquaretestbExcludesunknown(forTNM,n=203;forER/PRn=14)乳腺癌：并發(fā)疾病普遍存在hypertension(22.4%),chronicgastritis(14.3%),diabetesmellitus(6.2%),chronicbronchitis/asthma(5.8%),coronaryheartdisease(5.0%),andstroke(2.2%).第20頁，共32頁幻燈片。NHypertensionDiabetesCHDStrokeNHypertensionDiabetesCHDStrokeChronicGastritisn%n%n%n%n%Mastectomyc

No3055618.4175.6154.9103.34414.4

Yes4,35998922.72716.22175.0912.162514.3Chemotherapy

No35516646.86217.56117.2246.86117.2

Yes4,30987920.4a2265.2a1714.0a771.8a60814.1Radiotherapy

No3,12778225.02096.71896.0772.547615.2

Yes1,53726317.1a795.1a432.8a241.619312.6aTamoxifenuse

No2,24450022.31426.31064.7462.132514.5

Yes2,42054522.51466.01265.2552.334414.2乳腺癌：并發(fā)疾病普遍存在aPvalue<0.05basedonChisquaretestcExcludeswomenwhodidnotundergosurgery(n=10)高血壓，糖尿病，冠心病或中風與高齡，超重（BMI25-<30kg/m2）有關(guān)放療和化療也與高血壓、糖尿病、冠心病和中風相關(guān)第21頁，共32頁幻燈片。NHypertensionDiabetesCHDStroke并發(fā)疾病影響乳腺癌生存ComorbiditiesCohortRecurrence/metastasisTotalmortalityEventsModelAaModelBbEventsModelAaModelBbHR(95

%

CI)HR(95

%

CI)HR(95

%

CI)HR(95

%

CI)Specificallyassessedc

Diabetes288441.10(0.80–1.52)0.98(0.71–1.36)671.55(1.18–2.03)*1.40(1.06–1.85)*

Hypertension1,0451390.91(0.74–1.12)0.83(0.67–1.03)1570.88(0.72–1.07)0.83(0.67–1.02)

CHD232290.81(0.55–1.21)0.85(0.57–1.27)360.80(0.56–1.15)0.80(0.56–1.15)

Stroke101100.60(0.31–1.15)0.63(0.33–1.20)231.29(0.83–2.02)1.42(0.91–2.22)

Chronicbronchitis/asthma268441.13(0.83–1.54)1.00(0.73–1.38)471.09(0.81–1.47)0.96(0.70–1.30)

Chronicgastritis669910.97(0.77–1.21)1.14(0.91–1.43)740.74(0.58–0.94)*0.89(0.69–1.14)

Chronichepatitis82121.11(0.62–1.97)1.16(0.65–2.06)70.60(0.28–1.26)0.64(0.30–1.35)*Pvalue<0.05糖尿病與總死亡率風險增加有關(guān)第22頁，共32頁幻燈片。并發(fā)疾病影響乳腺癌生存ComorbiditiesCohort并發(fā)疾病與乳腺癌生存：來自上海的研究報告comorbiditiesCohortBreastcancer-specificmortalityNon-breastcancerspecificmortalityEventsModelAaModelBbEventsModelAaModelBbHR(95

%

CI)HR(95

%

CI)HR(95

%

CI)HR(95

%

CI)Specificallyassessedc

Diabetes288361.14(0.80–1.62)0.98(0.68–1.41)313.00(1.90–4.73)*2.64(1.63–4.27)*

Hypertension1,0451100.87(0.69–1.09)0.82(0.64–1.04)470.95(0.62–1.43)0.92(0.60–1.41)

CHD232200.66(0.41–1.06)0.64(0.40–1.03)161.15(0.64–2.06)1.29(0.70–2.36)

Stroke10180.68(0.33–1.40)0.78(0.38–1.62)152.55(1.38–4.71)*2.52(1.33–4.78)*

Chronicbronchitis/asthma268351.07(0.75–1.51)0.93(0.65–1.33)121.17(0.64–2.13)1.03(0.55–1.91)

Chronicgastritis669620.80(0.61–1.05)0.99(0.76–1.31)120.53(0.29–0.96)*0.55(0.30–1.01)

Chronichepatitis8260.64(0.29–1.44)0.70(0.31–1.59)NAe

NAe

*Pvalue<0.05糖尿病和中風病史與非乳腺癌死亡率相關(guān)、但與乳腺癌特異性死亡率無關(guān)第23頁，共32頁幻燈片。并發(fā)疾病與乳腺癌生存：來自上海的研究報告comorbiditNHypertensionDiabetesCHDStrokeChronicGastritisn%n%n%n%n%Ageatdiagnosis,y

<502,0931728.2391.930.1430.1422610.8

50–591,37230622.3624.5433.1161.222616.5

≥601,19956747.3a18715.6a18615.5a826.8a21718.1aTNMstageb

I1,62236022.2875.4845.2342.128217.4

II2,39453022.11476.11134.7482.030512.7

III44511024.7378.3a235.2132.94911.0aER/PRstatusb

ER+/PR+2,37953722.61476.21154.8562.434414.5

ER+/PR?61616827.3437.0386.2162.68614.0

ER?/PR+3516217.7133.7113.151.45014.3

ER?/PR?1,30426920.6a836.4675.1221.718914.5Mastectomyc

No3055618.4175.6154.9103.34414.4

Yes4,35998922.72716.22175.0912.162514.3Chemotherapy

No35516646.86217.56117.2246.86117.2

Yes4,30987920.4a2265.2a1714.0a771.8a60814.1Radiotherapy

No3,12778225.02096.71896.0772.547615.2

Yes1,53726317.1a795.1a432.8a241.619312.6aTamoxifenuse

No2,24450022.31426.31064.7462.132514.5

Yes2,42054522.51466.01265.2552.334414.2BMI(kg/m2)

<25.03,04748616.01555.11103.6521.746015.1

25.0–29.991,36242631.31138.3926.8423.218413.5

≥3025513352.2a207.8a3011.8a72.7a259.7a第24頁，共32頁幻燈片。NHypertensionDiabetesCHDStroke乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響診斷后生活方式因素的影響：體重指數(shù)（BMI），選擇并發(fā)疾?。▋H限糖尿病，僅高血壓，或兩者兼有）和極低體力活動（定義為體力活動<1.5METh/周）在單個模型中以及在多變量模型中與乳腺癌死亡率的影響。BreastCancerResTreat.2016Feb;155(3):551-7.第25頁，共32頁幻燈片。乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響診斷后生活方式因乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響

Deaths/NModel1Model2Model3Model4Bodymassindex

Underweight(<18.5)21/1391.45(0.83–2.53)

1.41(0.81–2.45)

Normal(18.5–24.9)429/3889Reference

Reference

Overweight(25.0–29.9)389/31541.07(0.92–1.25)

1.05(0.90–1.22)

ObeseI(30.0–34.9)192/14711.10(0.91–1.33)

1.04(0.86–1.27)

ObeseII(≥35.0)100/8601.05(0.83–1.32)

0.95(0.74–1.20)Comorbidities

None715/6037

Reference

Reference

Diabetes29/198

1.49(0.99–2.23)*

1.43(0.95–2.15)*

Hypertension332/2855

1.12(0.96–1.31)

1.11(0.95–1.30)

Hypertension&diabetes55/423

1.34(0.97–1.85)*

1.32(0.95–1.84)*Physicalactivity

Low(METh/week<1.5)274/1865

1.22(1.05–1.42)**1.21(1.03–1.41)**

Not-low(METh/week≥1.5)857/7648

ReferenceReference*pvalue<0.1,**pvalue<0.05合并癥中糖尿病以及低體力活動影響乳腺癌相關(guān)的死亡風險第26頁，共32頁幻燈片。乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響

Deaths/乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響

Deaths/NModel1Model2Model3Model4Bodymassindex

Underweight(<18.5)67/1392.48(1.84–3.34)**

2.32(1.72–3.12)**

Normal(18.5–24.9)817/3889Reference

Reference

Overweight(25.0–29.9)731/31541.05(0.94–1.17)

1.00(0.89–1.11)

ObeseI(30.0–34.9)377/14711.19(1.05–1.36)**

1.06(0.92–1.21)

ObeseII(≥35.0)220/8601.31(1.12–1.54)**

1.05(0.88–1.24)Comorbidities

None1148/6037

Reference

Reference

Diabetes70/198

1.89(1.45–2.45)**

1.77(1.36–2.30)**

Hypertension805/2855

1.30(1.17–1.44)**

1.27(1.14–1.42)**

Hypertension&diabetes189/423

2.29(1.91–2.74)**

2.16(1.79–2.60)**Physicalactivity

Low(METh/week<1.5)594/1865

1.43(1.29–1.59)**1.35(1.22–1.51)**

Not-low(METh/week≥1.5)1618/7648

ReferenceReference**pvalue<0.05BMI、合并癥以及低體力活動影響全因死亡風險第27頁，共32頁幻燈片。乳腺癌預(yù)后患者中運動、BMI和并發(fā)疾病的影響

Deaths/ComorbiditiesCohortRecurrence/metastasisTotalmortalityEventsModelAaModelBbEventsModelAaModelBbHR(95

%

CI)HR(95

%

CI)HR(95

%

CI)HR(95

%

CI)Specificallyassessedc

Diabetes288441.10(0.80–1.52)0.98(0.71–1.36)671.55(1.18–2.03)*1.40(1.06–1.85)*

Hypertension1,0451390.91(0.74–1.12)0.83(0.67–1.03)1570.88(0.72–1.07)0.83(0.67–1.02)

CHD232290.81(0.55–1.21)0.85(0.57–1.27)360.80(0.56–1.15)0.80(0.56–1.15)

Stroke101100.60(0.31–1.15)0.63(0.33–1.20)231.29(0.83–2.02)1.42(0.91–2.22)

Chronicbronchitis/asthma268441.13(0.83–1.54)1.00(0.73–1.38)471.09(0.81–1.47)0.96(0.70–1.30)

Chronicgastritis669910.97(0.77–1.21)1.14(0.91–1.43)740.74(0.58–0.94)*0.89(0.69–1.14)

Chronichepatitis82121.11(0.62–1.97)1.16(0.65–2.06)70.60(0.28–1.26)0.64(0.30–1.35)Volunteeredd

Digestiveulcer7490.88(0.46–1.71)0.93(0.48–1.82)70.58(0.28–1.24)0.59(0.28–1.26)

Rheumatoidarthritis65101.12(0.60–2.11)1.24(0.66–2.34)151.68(1.00–2.81)1.91(1.13–3.23)*

Otherdigestivedisease492660.97(0.75–1.25)0.98(0.76–1.28)711.03(0.80–1.32)1.07(0.83–1.38)

Otherurinarysystemdisease8190.72(0.37–1.39)0.77(0.40–1.49)70.53(0.25–1.13)0.59(0