老年婦女發生股骨骨折死亡率比乳癌死亡率高


  May 18, 2007 — 根據一項發表於華勝頓西雅圖美國老年學會(AGS)年會的研究顯示,老年婦女發生股骨骨折死亡率比乳癌死亡率高。研究者表示,需要增加對於股骨骨折相關死亡率的認知,以改善預防措施。
  
  共同作者賓州匹茲堡大學流行病學教授Jane A. Cauley向Medscpae表示,該研究應該引起股骨骨折對於老年婦女生活影響的注意。大眾對於乳癌所帶來公共衛生的影響已有許多的認知,但事實上,我們的研究顯示,這個族群罹患乳癌的死亡率比股骨骨折低;即使校正後,股骨骨折公共衛生對於死亡率的影響比乳癌高。
  
  為了檢驗股骨骨折的存活率比乳癌低,研究者比較一群收納於SOF ( the Study of Osteoporotic Fractures ) 試驗中的9,704位婦女意外股骨骨折與侵襲性乳癌診斷後存活率,所有的收納對象年齡都高於65歲,平均後續追蹤時間為12.4 ± 2.9年,且95%病患有完整後續追蹤資料。
  
  診斷至死亡或最後一次後續追蹤的時間,以整個後續追蹤時間扣掉診斷時的時間表示,且股骨骨折後存活率、或是乳癌診斷透過單一變項或多變項存活分析比較。SOF研究中所包含的共變項資料包括流行病學、整體健康、功能狀態、與認知精神狀況。
  
  在後續追蹤中,有457件經由病理報告確認的侵襲性乳癌事件發生,另外有803件由放射學檢驗確認的股骨骨折案例;相較於被診斷罹患侵入性乳癌的病患,那些股骨骨折的婦女年齡較大,且教育程度較高、身體質量指數(BMI)較低、精神狀況較差、且體重變化較少。
  
  在股骨骨折後,整體死亡率為48.1%(共有386位病患),相較於被診斷罹患乳癌的25.1%(共有94位)(P<0.0001),且存活估計有顯著差異(log rank檢定值為134.63;P<0.0001);股骨骨折的死亡率為每1000人每年40.5件、相較於乳癌的15.4件,剩下的病患為27.9件;在校正BMI、年齡、教育程度、精神狀況、自25歲後的體重變化、功能狀態、健康自我評比、以及花在足部照護的時間後,並未破壞這存活率上的差異 【可能性比值為226.16;P<0.0001;危險比值為0.376(95%信賴區間為0.295至0.480)】。
  
  作者的結論是,老年婦女在發生股骨骨折後的死亡率比診斷乳癌後高,且對於股骨骨折相關死亡率認知的提升必須增進預防措施的改善。
  
  荷蘭Groiningen大學醫學中心骨外科教授S. K. Bulstra醫師向Medscape表示,這項研究的意義是,我們應該針對股骨骨折病患的正確治療進行更多的研究;Bulstra醫師並未參與這項研究,但是被Medscape要求提供獨立意見。
  
  Bulstra醫師表示,當然了解這些病患是否比乳癌病患有更多其他疾病是重要的,股骨骨折組病患的體重下降暗示發生骨質疏鬆頻率較高;病患是否來自家庭或是安養中心、以及其精神狀況是如何被評量的同樣是重要的,因為存活與精神狀態之間的確是有關聯的。
  
  Bulstra醫師的研究與經驗顯示,雖然存活率在2年後趨向穩定,但股骨骨折10年後的死亡率增加;許多病患在股骨骨折後不再能夠住在家裡,這與她們在股骨骨折前後的行走能力有關;心臟衰竭、腎臟衰竭、肝臟疾病、淋巴瘤體重下降,這些因子每年大約增加死亡風險2倍。
  
  Cauley博士的結論是,未來的研究應該比較股骨骨折與乳癌對於這群病患生活品質的影響,包括功能性失能、疼痛、行動力、與其他預後方面。
  
  由美國聯邦老年研究與國家老年機構資助的老年領域醫學生訓練計畫協助這項研究。Cauley博士與Bulstra醫師表示無相關資金上的往來。

Mortality Greater for Hip Frac

By Laurie Barclay, MD
Medscape Medical News

May 18, 2007 — Older women are at greater risk for death after hip fracture than after breast cancer, according to a presentation at the American Geriatrics Society (AGS) annual meeting held in Seattle, Washington. The investigators suggest that increased awareness of mortality associated with hip fracture is needed to improve preventive measures.

"This study should raise the general level of awareness of the impact of hip fracture on the lives of elderly women," coauthor Jane A. Cauley, DrPH, a professor of epidemiology at the University of Pittsburgh in Pennsylvania, told Medscape. "There is already a greater general level of awareness of the public health impact of breast cancer, but, in fact, our study showed that the mortality of breast cancer in this population was less than that of hip fracture. The public health impact on mortality was much greater for hip fracture than for breast cancer, even after adjustment."

To test the hypothesis that hip fracture would be associated with worse survival than breast cancer, the investigators compared survival after an incident hip fracture and a diagnosis of invasive breast cancer in a longitudinal cohort of 9704 women enrolled in the Study of Osteoporotic Fractures (SOF). Participants were all aged 65 years or older at enrollment. Mean duration of follow-up was 12.4 ± 2.9 years, and follow-up of the cohort is over 95% complete.

Time from diagnosis to death or last follow-up was calculated by subtracting the time at diagnosis from the total follow-up time, and survival after hip fracture or diagnosis of breast cancer were compared using univariate and multivariate survival analysis. Covariate data available in SOF included demographics, general health, functional status, and cognitive mental status.

During follow-up, there were 457 incident cases of invasive breast cancer confirmed by pathology report, and 803 incident cases of hip fracture confirmed from radiographic reports. Compared with women diagnosed with invasive breast cancer, those with hip fracture were older, with higher levels of education, lower body mass index (BMI), decreased mental status, and less weight change.

After hip fracture, total mortality was 48.1% (n = 386) compared with 25.1% (n = 94) after diagnosis of breast cancer (P < .0001), and survival estimates were significantly different (log rank, 134.63; P < .0001). Mortality rates per 1000 person-years were 40.5 for hip fracture, 15.4 for breast cancer, and 27.9 for the remaining cohort. Adjustment for BMI, age, education, mental status, weight change since age 25 years, functional status, self-rated health, and amount of time spent on feet did not abolish this survival difference (likelihood ratio, 226.16; P < .0001; hazard ratio, 0.376 (95% confidence interval, 0.295 - 0.480).

The authors concluded that older women are at a greater risk for death after hip fracture than after breast cancer diagnosis, and that increased awareness of mortality associated with hip fracture is needed to promote preventive measures.

"The implications of this study are that we should aim more studies at the correct treatment of the patient with a hip fracture," S. K. Bulstra, MD, a professor of orthopaedic surgery at the University Medical Center Groiningen in the Netherlands, told Medscape. Dr. Bulstra was not involved with this study but was asked by Medscape to provide independent commentary.

"Of course it is important to know whether these patients also had more comorbidity than the breast cancer patients," Dr. Bulstra said. "The reduced weight of the hip fracture group suggests a higher frequency of osteoporosis. It is also important to know if patients came from a home situation or a nursing home and how the mental status was assessed, because indeed there is a connection between survival and mental status."

Dr. Bulstra's own research and experience suggest an increased mortality rate for 10 years or more after hip fracture, although the survival rate stabilizes after 2 years. Many patients are no longer able to live at home after hip fracture, which is related to their walking ability both before and after the fracture. Congestive heart failure, renal failure, liver disease, lymphoma, and weight loss each increased the 1-year mortality risk by approximately 2-fold.

"Future studies should compare the effect of hip fracture and of breast cancer on quality of life in this population, in terms of functional disability, pain, mobility, and other outcomes," Dr. Cauley concluded.

Medical Student Training in Aging Research, which is sponsored by the American Federation for Aging Research and the National Institute on Aging, helped support this study. Dr. Cauley and Dr. Bulstra report no relevant financial relationships.

AGS 2007 Annual Scientific Meeting: Abstract P28. May 2-6, 2007.


    
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