Influence of Social Determinants of Health on Overall Survivals among People Died of Cancer
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摘要:
目的 从健康社会决定因素角度分析云南省恶性肿瘤死亡人群的存活差异,为有针对性地制定防治策略提供依据。 方法 利用Stata15.1整理分析2015年至2019年云南省恶性肿瘤死亡数据,采用多元线性回归控制相关协变量获得调整后的总生存时间(OS),分析比较各健康社会决定因素(年龄、性别、居住地区、民族、文化程度、职业和婚姻状况)对恶性肿瘤死亡人群OS的影响,同时对因17种恶性肿瘤死亡的人群OS进行亚组分析。 结果 云南省2015年至2019年因恶性肿瘤死亡人群中登记了OS信息的有128 356人,平均OS为(17.28±23.33)月。因恶性肿瘤死亡的人群中,年龄65岁以下、男性、居住在农村、少数民族、初中及以下学历、农民、非在婚人群的平均OS较短(P < 0.001);但是在深度贫困县和“直过民族”因恶性肿瘤死亡人群的平均OS分别比在一般贫困县和其他少数民族长(P < 0.001)。控制了混杂因素后,年龄、性别、居住地、民族、学历、职业、婚姻状态仍然对恶性肿瘤OS有影响(P < 0.001),但在不同恶性肿瘤中各健康社会决定因素对OS的影响不同。 结论 云南省最脆弱地区和群体的恶性肿瘤患病生存得到改善,但不同人群恶性肿瘤的OS仍存在较大差异,需有针对性地制定恶性肿瘤防治策略,促进健康公平。 Abstract:Objective To analyze the differences in overall survival (OS) among people died of cancer in Yunnan from the perspective of social determinants of health, and provide evidence to the strategic plan for cancer prevention and control. Methods Death registry data on cancer in Yunnan from 2015 to 2019 were analyzed using Stata 15.1. Adjusted OS was predicted by multivariate linear regression after controlling the confounding variables. The impacts of social determinants of health (such as age, sex, residential area, ethnicity, educational level, occupation, and marital status) on OS among people died of cancer were estimated, and subgroup analyses were conducted for 17 kinds of malignant tumors. Results Totally 128,356 people with the information OS after a cancer diagnosis were recorded in Yunnan from 2015 to 2019, with an average OS of (17.28±23.33) months. The average OS due to cancer was shorter among people under 65 years old, male, living in rural area, belonging an ethnic minority group, with junior high school education or below, being peasant, or unmarried, compared with their counterparts (P < 0.001). However, people living in severely impoverished counties and belonging to an “Zhiguo ethnicity” separately have longer OS after a cancer diagnosis than those living in other poor counties and belonging other ethnic minority groups (P < 0.001). The effects of age, sex, residential area, ethnicity, educational level, occupation, or marital status on OS remained after controlling the confounding factors (P < 0.001), but varied among different cancers. Conclusions The cancer survivals in the most vulnerable areas and people have been improved in Yunnan. However large differences exist in the OS among different people with cancer. Strategic plan for cancer prevention and control is needed in future to promote health equity. -
Key words:
- Cancer /
- Overall survival /
- Social determinants of health /
- Health equity
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表 1 2015年-2019年云南省因恶性肿瘤死亡的不同人群总生存时间[(
$\bar x \pm s $ )/M(P5,P95),月]Table 1. Overall survivals among different people died of cancer in Yunnan Province,2015-2019 [(
$\bar x \pm s $ )/M(P5,P95),months]健康社会决定因素 N 平均OS Fa P 中位OS Z/H P OS构成比(%) χ2 P < 3 3~ 24~ 60~ 年龄(岁) 41 460 < 0.001* 134.645 < 0.001* 228.421 < 0.001* 0~14 905 12.32 ± 16.26 6.00(0.30,43.20) 25.86 53.48 18.01 2.65 15~64 56 905 17.05 ± 21.37 12.00(1.00,60.00) 12.53 57.15 24.67 5.65 65~ 70 546 17.52 ± 24.85 12.00(1.00,60.00) 13.69 56.87 23.12 6.32 性别 400.450 < 0.001* 18.690 < 0.001* 352.369 < 0.001* 男 82 049 16.39 ± 21.98 12.00(1.00,60.00) 13.81 58.08 22.74 5.36 女 46 307 18.87 ± 24.47 12.00(1.00,60.00) 12.29 55.00 25.60 7.11 地区分类1 73.430 < 0.001* −0.661 0.508 413.819 < 0.001* 城市 29 225 19.14 ± 29.39 12.00(1.00,60.00) 14.92 54.81 22.22 8.05 农村 99 131 16.73 ± 21.18 12.00(1.00,60.00) 12.78 57.61 24.23 5.39 地区分类2 46.210 < 0.001* 113.019 < 0.001* 377.619 < 0.001* 非贫困县 18 371 16.66 ± 22.22 12.00(1.00,60.00) 13.63 57.65 23.34 5.38 一般贫困县 54 809 16.38 ± 20.85 12.00(1.00,60.00) 12.80 58.56 23.45 5.19 深度贫困县 25 951 17.51 ± 21.11 12.00(1.00,60.00) 12.13 55.56 26.50 5.81 民族 汉族 91 164 17.65 ± 23.95 94.770 < 0.001* 12.00(1.00,60.00) 9.166 < 0.001* 12.94 56.82 23.98 6.26 68.265 < 0.001* 少数民族 37 192 16.37 ± 21.71 12.00(1.00,60.00) 14.06 57.33 23.26 5.35 直过民族 4 271 17.56 ± 21.43 20.330 < 0.001* 12.00(1.00,60.00) 4.754 < 0.001* 13.81 54.65 25.31 6.23 22.007 < 0.001* 其他少数民族 32 921 16.22 ± 21.75 12.00(1.00,60.00) 14.09 57.68 23.00 5.23 文化程度 135.590 < 0.001* −8.346 < 0.001* 168.622 < 0.001* 初中及以下 118 151 17.02 ± 22.82 12.00(1.00,60.00) 13.25 57.28 23.73 5.75 初中以上 10 205 20.35 ± 28.36 12.00(1.00,72.00) 13.48 53.44 24.30 8.77 职业 240.800 < 0.001* −5.321 < 0.001* 647.171 < 0.001* 农民 102 429 16.54 ± 21.11 12.00(1.00,60.00) 12.79 57.95 24.00 5.25 非务农人群 25 927 20.19 ± 30.38 12.00(1.00,72.00) 15.14 53.08 22.86 8.92 婚姻状况 31.220 < 0.001* 8.633 < 0.001* 122.306 < 0.001* 在婚 102 177 17.33 ± 22.92 12.00(1.00,60.00) 12.79 57.08 24.18 5.95 其他 26 179 17.07 ± 24.87 12.00(1.00,60.00) 15.11 56.53 22.18 6.17 肿瘤类别b 1337.040 < 0.001* 2286.174 < 0.001* 2300.000 < 0.001* 5 a生存率较低 62 413 15.20 ± 20.21 12.00(1.00,48.00) 14.93 59.43 21.03 4.60 5 a生存率中等 57 668 18.03 ± 24.06 12.00(1.00,60.00) 12.32 55.94 25.36 6.38 5 a生存率较高 8 275 27.67 ± 34.33 12.00(2.00,96.00) 7.27 45.61 33.33 13.79 注:N为死亡人数;OS为总生存时间;$\bar x \pm s $为均数 ± 标准差;M(P5,P95)为中位数和第5/95百分位数;
a对经平方根正态转换后的OS进行方差分析;b5 a生存率较低的恶性肿瘤包括肺癌、肝癌、白血病、胰腺癌,5 a生存率中等的恶性肿瘤包括胃癌、结直肠癌、食道癌、子宫颈癌、淋巴瘤与多发性骨髓瘤、唇、口腔和咽恶性肿瘤、卵巢癌、皮肤癌、其他恶性肿瘤,5 a生存率较高的恶性肿瘤包括乳腺癌、膀胱癌、前列腺癌、子宫体癌;*P < 0.05。表 2 2015年-2019年云南省因恶性肿瘤死亡的不同人群总生存调整时间[(
$\bar x \pm s $ )/M(P5,P95),月]Table 2. Adjusted overall survivals among different people died of cancer in Yunnan Province, 2015-2019 [(
$\bar x \pm s $ )/M(P5,P95),months]健康社会决定因素 N 平均OS t P 中位OS Z/H P 年龄(岁) 1561.782 < 0.001* 0~14b 905 17.55 ± 2.54 17.55(13.94,21.76) 15~64 56 905 16.89 ± 3.32 −5.990 < 0.001* 17.02(12.32,23.16) 65~ 70 546 17.60 ± 3.28 0.460 0.645 17.53(13.23,23.60) 性别 136.449 < 0.001* 男b 82 049 16.39 ± 3.03 16.61(12.32,21.85) 女 46 307 18.87 ± 3.20 −138.080 < 0.001* 19.06(14.38,24.34) 地区分类1 100.823 < 0.001* 城市b 29 225 19.14 ± 3.54 18.71(13.68,25.15) 农村 99 131 16.73 ± 3.03 114.920 < 0.001* 16.62(12.59,22.44) 地区分类2 2437.254 < 0.001* 非贫困县b 18 371 17.96 ± 3.70 17.53(12.79,24.34) 一般贫困县 54 809 16.78 ± 3.03 −57.510 < 0.001* 17.03(12.32,22.44) 深度贫困县 25 951 17.10 ± 2.90 −34.190 < 0.001* 16.89(13.41,22.71) 民族 汉族b 91 164 17.65 ± 3.35 17.63(13.23,23.80) 65.362 < 0.001* 少数民族 37 192 16.37 ± 3.03 −63.850 < 0.001* 16.59(12.32,22.00) 直过民族b 4 271 17.56 ± 2.77 17.68(13.39,22.38) 26.673 < 0.001* 其他少数民族 32 921 16.22 ± 3.03 −27.470 < 0.001* 16.59(12.12,22.00) 文化程度 −89.418 < 0.001* 初中及以下b 118 151 17.02 ± 3.18 17.06(12.76,23.11) 初中以上 10 205 20.35 ± 3.31 101.430 < 0.001* 20.07(15.10,26.82) 职业 −146.090 < 0.001* 农民b 102 429 16.54 ± 2.93 16.59(12.59,22.00) 非务农人群 25 927 20.19 ± 3.14 176.550 < 0.001* 20.02(15.96,26.08) 婚姻状况 8.414 < 0.001* 在婚b 102 177 17.33 ± 3.32 17.50(12.79,23.60) 其他 26 179 17.07 ± 3.26 −11.340 < 0.001* 17.06(12.34,22.96) 肿瘤类别c 84878.211 < 0.001* 5 a生存率较低b 62 413 14.72 ± 1.83 14.37(12.32,18.47) 5 a生存率中等 57 668 19.08 ± 1.86 408.250 < 0.001* 18.83(16.59,22.99) 5 a生存率较高 8 275 24.02 ± 1.89 429.940 < 0.001* 23.80(21.31,27.63) 注:N为死亡人数;$\bar x \pm s $为调整均数 ± 标准差;M(P5,P95)为中位数和第5/95百分位数;
a调整OS符合正态分布;b参照组;c5 a生存率较低的恶性肿瘤包括肺癌、肝癌、白血病、胰腺癌,5 a生存率中等的恶性肿瘤包括胃癌、结直肠癌、食道癌、子宫颈癌、淋巴瘤与多发性骨髓瘤、唇、口腔和咽恶性肿瘤、卵巢癌、皮肤癌、其他恶性肿瘤,5 a生存率较高的恶性肿瘤包括乳腺癌、膀胱癌、前列腺癌、子宫体癌;*P < 0.05。表 3 2015年-2019年云南省因各类恶性肿瘤死亡的人群总生存调整时间[(
$\bar x \pm s $ ),月]aTable 3. Adjusted overall survivals among people died of various cancer in Yunnan Province, 2015-2019 [(
$\bar x \pm s $ ),months]a肿瘤名称
(N)年龄(岁) 性别 地区 民族 文化程度 职业 婚姻状况 0~14b 15~64 65~ 男b 女 城市b 农村 汉族b 少数民族 初中及以下b 初中以上 农民b 非务农人群 在婚b 其他 肺癌
(34 357)16.83 ± 0.84 14.39 ± 1.68a 15.05 ± 1.82a 14.35 ± 1.71 15.89 ± 1.51a 16.47 ± 1.94 14.30 ± 1.41a 15.12 ± 1.75 13.62 ± 1.42a 14.56 ± 1.59 17.77 ± 1.64a 14.11 ± 1.14 17.58 ± 1.18a 14.88 ± 1.81 14.47 ± 1.71a 肝癌
(20 972)15.54 ± 1.29 14.03 ± 1.66a 14.91 ± 1.82a 13.99 ± 1.63 15.74 ± 1.57a 16.19 ± 2.00 13.97 ± 1.39a 14.95 ± 1.78 13.45 ± 1.35a 14.21 ± 1.57 17.47 ± 1.74a 13.82 ± 1.13 17.49 ± 1.24a 14.51 ± 1.78 14.15 ± 1.82a 胃癌
(13 597)—c 18.36 ± 1.64 18.97 ± 1.64 18.11 ± 1.49 19.78 ± 1.40a 20.44 ± 2.04 18.38 ± 1.33a 19.32 ± 167 17.95 ± 1.29a 18.57 ± 1.48 21.93 ± 1.78a 18.30 ± 1.16 21.92 ± 1.29a 18.81 ± 1.69 18.47 ± 1.56a 结直肠癌
(10 766)18.55 ± 0.48 18.98 ± 1.93 19.73 ± 2.03 18.86 ± 1.92 20.39 ± 1.82a 21.25 ± 1.94 18.69 ± 1.50a 19.91 ± 1.98 18.16 ± 1.51a 19.13 ± 1.78 22.35 ± 1.63a 18.48 ± 1.17 22.18 ± 1.24a 19.58 ± 2.04 19.08 ± 1.92a 食道癌
(5 028)—c 18.00 ± 1.50 18.69 ± 1.58 18.16 ± 1.49 19.84 ± 1.41a 20.18 ± 1.90 18.08 ± 1.31a 18.88 ± 1.54 17.58 ± 1.29a 18.17 ± 1.37 21.37 ± 1.54a 17.88 ± 0.99 21.37 ± 1.13a 18.43 ± 1.57 18.08 ± 1.60a 白血病
(4 012)15.49 ± 1.42 14.74 ± 1.83a 15.54 ± 1.98 14.30 ± 1.73 15.95 ± 1.64a 16.61 ± 1.98 14.57 ± 1.56a 15.44 ± 1.87 14.10 ± 1.52a 14.75 ± 1.67 17.43 ± 1.83a 14.14 ± 1.19 17.05 ± 1.55a 15.02 ± 1.86 15.07 ± 1.91 子宫颈癌
(3 143)—c 19.80 ± 1.47 20.13 ± 1.48 —c 19.91 ± 1.48 21.57 ± 1.74 19.48 ± 1.04a 20.33 ± 1.48 19.06 ± 1.06a 19.74 ± 1.27 23.07 ± 1.56a 19.40 ± 0.75 23.01 ± 0.91a 19.99 ± 1.47 19.58 ± 1.50a 乳腺癌
(3 137)—c 24.37 ± 1.73 24.90 ± 1.90 22.89 ± 1.54 24.58 ± 1.79a 26.22 ± 1.83 23.82 ± 1.22a 24.96 ± 1.79 23.38 ± 1.23a 24.20 ± 1.49 27.53 ± 1.57a 23.65 ± 0.81 27.41 ± 0.95a 24.57 ± 1.87 24.35 ± 1.89a 胰腺癌
(3 072)—c 14.88 ± 2.03 15.74 ± 2.10 14.79 ± 2.01 16.30 ± 1.94a 17.14 ± 1.98 14.53 ± 1.57a 15.78 ± 2.07 13.94 ± 1.58a 14.95 ± 1.82 18.21 ± 1.56a 14.19 ± 1.16 17.94 ± 1.25a 15.47 ± 2.13 15.07 ± 2.02a 淋巴瘤与多
发性骨髓瘤
(2 556)19.62 ± 1.32 18.77 ± 1.81a 19.59 ± 2.04 18.58 ± 1.83 20.18 ± 1.73a 20.97 ± 1.99 18.56 ± 1.50a 19.65 ± 1.95 18.06 ± 1.44a 18.82 ± 1.68 21.88 ± 1.79a 18.29 ± 1.16 21.77 ± 1.43a 19.21 ± 1.94 18.99 ± 1.97a 唇/口腔/咽
恶性肿瘤
(2 227)17.93 ± 2.35 18.71 ± 1.83 19.16 ± 1.82 18.50 ± 1.78 19.99 ± 1.55a 20.65 ± 1.95 18.37 ± 1.41a 19.38 ± 1.81 17.88 ± 1.43a 18.61 ± 1.58 21.86 ± 1.51a 18.17 ± 1.12 21.72 ± 1.21a 18.99 ± 1.84 18.62 ± 1.80a 膀胱癌
(1 975)—c 22.73 ± 1.70 23.50 ± 1.91 23.04 ± 1.82 24.56 ± 1.70a 25.08 ± 1.83 22.63 ± 1.38a 23.72 ± 1.86 22.03 ± 1.39a 23.11 ± 1.70 26.33 ± 1.59a 22.46 ± 1.06 26.05 ± 1.15a 23.52 ± 1.89 22.91 ± 1.84a 前列腺癌
(1 774)—c 22.86 ± 1.93 23.76 ± 2.02 23.69 ± 2.03 —c 25.38 ± 1.64 22.60 ± 1.41a 24.03 ± 1.96 22.22 ± 1.62a 23.19 ± 1.73 26.55 ± 1.02a 22.15 ± 0.76 25.90 ± 0.93a 23.91 ± 2.01 22.88 ± 1.87a 子宫体癌
(1 389)—c 24.06 ± 1.39 24.41 ± 1.51 —c 24.21 ± 1.45 25.65 ± 1.76 23.80 ± 1.03a 24.68 ± 1.42 23.31 ± 1.03a 24.06 ± 1.25 27.43 ± 1.69a 23.73 ± 0.77 27.34 ± 0.91a 24.30 ± 1.41 23.89 ± 1.58a 卵巢癌
(923)21.34 ± 0.37 20.59 ± 1.98 21.23 ± 2.03 —c 20.83 ± 2.02 22.52 ± 1.72 19.74 ± 1.34a 21.29 ± 1.95 19.37 ± 1.48a 20.33 ± 1.69 23.52 ± 1.44a 19.46 ± 0.80 23.28 ± 0.91a 20.86 ± 2.03 20.72 ± 1.97 皮肤癌
(915)20.53 ± 1.18 18.83 ± 1.95a 19.24 ± 1.63 18.36 ± 1.59 19.93 ± 1.55a 20.55 ± 2.01 18.69 ± 1.43a 19.49 ± 1.74 18.10 ± 1.37a 18.90 ± 1.55 22.27 ± 1.66a 18.53 ± 1.16 22.00 ± 1.33a 19.26 ± 1.81 18.81 ± 1.62a 其他恶性
肿瘤
(18 513)19.69 ± 1.45 18.69 ± 1.74a 19.42 ± 1.89a 18.45 ± 1.66 20.17 ± 1.63a 20.94 ± 2.02 18.62 ± 1.47a 19.52 ± 1.81 18.03 ± 1.46a 18.82 ± 1.63 21.84 ± 1.78a 18.36 ± 1.16 21.78 ± 1.39a 19.14 ± 1.83 18.87 ± 1.87a 注:N为各恶性肿瘤死亡人数;$\bar x \pm s $为均数 ± 标准差;a调整OS符合正态分布,t检验的P<0.05;b参照组;c恶性肿瘤死亡例数为1例,或只存在于男性(前列腺癌)或女性(子宫颈癌、子宫体癌、卵巢癌)。 -
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