由于人口的增长和老龄化，以及早期发现和治疗的进步，癌症生存者数量持续增加。为了帮助公共卫生界更好地服务这些个体，美国癌症学会和国家癌症研究所每三年合作一次，利用监测流行病学最终结果（SEER）癌症登记数据库的发病和生存数据、疾病控制预防中心（CDC）全国卫生统计中心人口统计数据、美国人口普查局人口预测数据对全国癌症患病（新旧病例）数量进行推算，根据全国癌症数据库（NCD）对最常见癌症种类的现有治疗方式进行分析，并对癌症相关和治疗相关的短期、长期、晚期健康影响进行简要描述。
2019年6月11日，影响因子全球第一神刊、美国癌症学会《临床医师癌症杂志》在线发表美国癌症学会、国家癌症研究所、史密斯康复艺术中心、埃默里大学的2019年癌症治疗与生存统计报告。
截至2019年1月1日，美国癌症生存者超过1690万，其中男性810万、女性880万；根据人口的增长和老龄化趋势，预计截至2030年1月1日该数字将超过2210万。患者被诊断为癌症后，生存≥5年超过三分之二（68%），生存≥10年占45%，生存≥20年占18%。年龄≥65岁的生存者将近三分之二（64%）。
2019年最常见的癌症（图1）前三位：
男性：前列腺癌3650030例、结直肠癌776120例、黑色素瘤684470例（皮肤）
女性：乳腺癌 3861520例、子宫体癌807860例、结直肠癌768650例
图1：按部位推算的美国癌症生存者数量。这些数据不包括膀胱以外任何部位的原位癌，并且不包括基底细胞或鳞状细胞皮肤癌。
根据推算，2019年美国女性乳腺浸润癌生存者超过380万例，新诊断者预计26.86万例。乳腺癌IV期生存者超过15万例，其中初诊尚为I～III期占四分之三。年龄≥65岁的女性乳腺癌生存者超过240万，大约占64%，而年龄<50岁的女性乳腺癌生存者大约占7%（图2）。乳腺癌与美国其他最常见的癌症（肺癌、结直肠癌、前列腺癌）相比，生存者年龄分布较小，部分由于诊断时中位年龄较小（61岁）。
图2：截至2019年1月1日，美国不同癌症种类、患病年龄、诊断年数的患病比例。这些数据不包括膀胱以外任何部位的原位癌，并且不包括基底细胞或鳞状细胞皮肤癌。
治疗与生存
早期（I～II期）乳腺癌女性的主要治疗方式为乳房保留（保乳）手术＋术后辅助放疗（49%），乳房切除手术患者占34%（图3）。相比之下，III期乳腺癌患者超过三分之二（68%）进行了乳房切除手术，其中大多数患者还接受了术后辅助化疗。晚期（IV期）转移性乳腺癌女性主要接受放疗±化疗（56%），四分之一未接受治疗，其中一些患者仅接受了内分泌治疗。对于激素受体阳性乳腺癌患者，接受激素治疗占81%，但是转移性乳腺癌患者比例略低（71%）。
图3：2016年不同分期女性乳腺癌治疗方式（%）。少数患者接受了化疗、放疗。BCS：保乳手术；CHEMO：化疗（包括靶向治疗和免疫治疗）。
对于局部或淋巴引流区域乳腺癌，保乳手术＋术后乳房放疗，与乳房切除手术相比，长期生存相似。不过，由于肿瘤特征（例如局部晚期、肿瘤较大或多发）或术后辅助放疗禁忌证（例如以前接受过放疗、已存在活动性结缔组织病等内科疾病）或其他障碍，某些患者需要乳房切除手术。符合保乳手术条件的女性，由于各种原因越来越多地选择乳房切除手术，包括不愿进行放疗和害怕复发。年轻女性（年龄<40岁）、肿瘤较大或恶性程度较高的乳腺癌患者，更有可能接受乳房切除手术治疗，尤其更有可能接受预防性对侧乳房切除手术。单侧未转移乳腺癌女性接受预防性对侧乳房切除手术的比例迅速增加，20～44岁女性由2004年10%增至2012年33%，≥45岁女性由2004年4%增至2012年10%。预防性对侧乳房切除手术比例，在美国中西部（中北部）最高，在东北部和西部最低，可能反映医师观念和实践以及患者相关因素的不同。随着预防性对侧乳房切除手术的增加，2017年纽约纪念医院斯隆凯特林癌症中心和密歇根大学发表的全国癌症数据库分析发现，乳房切除手术（单侧或双侧）接受即刻乳房重建的女性比例由2004年18%增至2013年41%，年轻、白人、个人医疗保险、高学历、接受预防性对侧乳房切除手术的女性更有可能进行乳房重建。
影响乳腺癌患者生存的生物学因素包括分期、肿瘤分级、雌激素和孕激素受体状态以及HER2状态。5年生存相对比例由1984～1986年的79%增至2008～2014年的91%，主要由于治疗水平提高（尤其激素受体阳性乳腺癌的芳香酶抑制剂等、HER2阳性乳腺癌的曲妥珠单抗等）以及早期诊断和乳腺钼靶筛查的普及。不过，三阴性（雌激素、孕激素、HER2阴性）乳腺癌与其他分子亚型相比，治疗进展落后，目前为止主要局限于化疗。最近，免疫治疗药物联合化疗被批准用于转移性三阴性乳腺癌。虽然目前正在开展若干免疫疗法和靶向疗法的研究，但是由于三阴性乳腺癌具有不同的分子特征，这些疗法可能仅对一部分患者有效。诊断时仅I期乳腺癌患者占44%，5年生存相对比例接近100%（图4）；诊断时已IV期乳腺癌患者占5%，5年生存相对比例降至26%。黑人女性与白人女性相比，诊断时为I期乳腺癌的比例较低（34%比46%）并且各个分期生存比例都较低。美国癌症学会的一项研究对其他临床因素进行校正后，对于乳腺癌非老年患者，黑人女性与白人女性相比，保险状况对生存的影响超过三分之一（37%），肿瘤生物学（例如黑人女性的三阴性癌症发病比例较高）、合并症、治疗方式对生存的影响分别占23.2%、11.3%、4.8%。
图4：2011～2015年不同种族的乳腺癌分期分布（%）。分期根据美国癌症联合委员会（AJCC）癌症分期手册第6版。NH：非西班牙裔；Unk：分期未知。
短期和长期的健康影响
手臂淋巴水肿发生于19.9%的腋窝淋巴结清扫女性、5.6%的前哨淋巴结活检女性，淋巴引流区域淋巴结放疗也可能增加风险，尤其对于腋窝淋巴结清扫患者，早期诊断淋巴水肿对于优化治疗和减缓进展非常重要。某些形式的癌症康复可以减少风险并且减轻严重程度。
手术和放疗的其他长期局部影响包括胸壁、手臂或肩膀的麻木、刺痛或紧绷。2018年加拿大多伦多大学森尼布鲁克健康科学中心发表的研究表明，大约三分之一的乳腺癌手术或放疗后女性出现持续疼痛，年轻女性和腋窝淋巴结清扫者的风险最高。
此外，化疗可以引起绝经提前，从而增加骨质疏松和生育能力障碍的风险。
紫杉类化疗经常引起神经病变，治疗后可以持续很长时间。
蒽环类和HER2靶向药物可以引起心肌病和充血性心力衰竭。对此，美国临床肿瘤学会发布了成人癌症生存者心功能障碍预防和监测的临床实践指南。
芳香酶抑制剂治疗通常仅用于绝经后女性，也可引起骨质疏松、肌肉疼痛、关节疼痛，而他莫昔芬可以轻微增加子宫内膜癌和血栓栓塞疾病的风险。乳腺癌内分泌治疗也可能引起绝经症状，例如潮热、盗汗，以及萎缩性阴道炎，可能造成性交困难。性功能障碍常见于乳腺癌生存者，但是往往无法解决。
乳腺癌生存者还可能发生认知障碍和慢性疲劳。
CA Cancer J Clin. 2019 Jun 11. [Epub ahead of print]
Cancer treatment and survivorship statistics, 2019.
Miller KD, Nogueira L, Mariotto AB, Rowland JH, Yabroff KR, Alfano CM, Jemal A, Kramer JL, Siegel RL.
American Cancer Society, Atlanta, Georgia; National Cancer Institute, Bethesda, Maryland; Smith Center for Healing and the Arts, Washington, DC; Emory University, Atlanta, Georgia.
The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described.
More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3650030), colon and rectum (776120), and melanoma of the skin (684470) among males, and breast (3861520), uterine corpus (807860), and colon and rectum (768650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care.
More than 16.9 million Americans with a history of cancer were alive on January 1, 2019, and this number is projected to grow to more than 22.1 million by January 1, 2030. These estimates do not include carcinoma in situ (CIS) of any site (except urinary bladder) or basal cell and squamous cell skin cancers. The 3 most prevalent cancers in 2019 are prostate (3650030), colon and rectum (776120), and melanoma (684470) among males, and breast (3861520), uterine corpus (807860), and colon and rectum (768650) among females (FIGURE 1). The distribution of prevalent cancers differs from that for incident cancers because prevalent cancers reflect survival and median age at diagnosis as well as cancer occurrence.
FIGURE 1: Estimated Number of US Cancer Survivors by Site. Estimates do not include in situ carcinoma of any site except urinary bladder and do not include basal cell or squamous cell skin cancers.
It is estimated that there are more than 3.8 million women living in the United States with a history of invasive breast cancer, and 268600 women will be newly diagnosed in 2019. More than 150000 breast cancer survivors are living with metastatic disease, three-quarters of whom were originally diagnosed with stage I through III cancer. Approximately 64% of breast cancer survivors (more than 2.4 million women) are aged 65 years and older, whereas 7% are aged younger than 50 years (FIGURE 2). The age distribution of breast cancer survivors is younger than that for the other most common incident cancers in the United States (lung, colorectum, and prostate), in part because the median age at diagnosis is younger (61 years).
FIGURE 2: Prevalence by Cancer Type, Years Since Diagnosis, and Age at Prevalence as of January 1, 2019, United States. Estimates do not include in situ carcinoma of any site except urinary bladder and do not include basal cell or squamous cell skin cancers.
TREATMENT AND SURVIVAL
The most common treatment among women with early-stage (stage I or II) breast cancer is breast-conserving surgery (BCS) with adjuvant radiation therapy (49%), although 34% of patients undergo mastectomy (FIGURE 3). By comparison, more than two-thirds (68%) of patients with stage III disease undergo mastectomy, most of whom also receive adjuvant chemotherapy. Women diagnosed with metastatic disease (stage IV) most often receive radiation and/or chemotherapy alone (56%), with one-quarter receiving no treatment (although some of these patients receive hormonal therapy). Among patients with hormone receptor-positive tumors, 81% receive hormonal therapy, although the percentage is slightly lower for those with metastatic disease (71%).
FIGURE 3: Female Breast Cancer Treatment Patterns (%) by Stage, 2016. A small number of these patients received chemotherapy. A small number of these patients received radiation therapy (RT). BCS indicates breast-conserving surgery; chemo, chemotherapy (includes targeted therapy and immunotherapy).
When BCS followed by radiation to the breast is appropriately used for localized or regional cancers, long-term survival is the same as that with mastectomy. However, some patients require mastectomy because of tumor characteristics (eg, locally advanced stage, large or multiple tumors), because adjuvant radiation is contraindicated (eg, previously received radiation, pre-existing medical conditions such as active connective tissue disease), or because of other obstacles. BCS-eligible women are increasingly electing mastectomy for a variety of reasons, including reluctance to undergo radiation therapy and fear of recurrence. Younger women (aged <40 years) and patients with larger and/or more aggressive tumors are more likely to be treated with mastectomy and are particularly more likely to also undergo a contralateral prophylactic mastectomy (CPM). The proportion of women undergoing surgery for nonmetastatic disease in one breast who receive CPM has increased rapidly, from 10% in 2004 to 33% in 2012 among women aged 20 to 44 years and from 4% to 10% during the same time period among those aged 45 years and older. CPM receipt is highest in the Midwest and lowest in the Northeast and West, which may reflect differences in physician beliefs and practices as well as patient-related factors. In parallel with the rise in CPM, a recent large study found that the 41% of women who underwent any mastectomy (unilateral or bilateral) received immediate breast-reconstructive procedures, up from 18% in 2004. Women who are younger, white, privately insured, or more highly educated, as well as those who undergo CPM, are more likely to undergo reconstruction.
Biological factors that influence breast cancer survival include stage, tumor grade, estrogen and progesterone hormone receptor status, and human epidermal growth factor receptor 2 (HER2) status. The 5-year relative survival rate has increased from 79% for patients diagnosed during 1984 through 1986 to 91% for those diagnosed during 2008 through 2014, largely because of improvements in treatment, especially for hormone receptor-positive and HER2-positive tumors (eg, aromatase inhibitors and trastuzumab, respectively), and earlier stage of disease at diagnosis with the increased prevalence of mammography screening. However, treatment advances for triple-negative tumors (estrogen and progesterone hormone receptor-negative and HER2-negative tumors) have lagged behind those for other molecular subtypes and thus far have been largely limited to chemotherapy. Recently, a combination of an immunotherapy drug with chemotherapy was approved for metastatic triple-negative breast cancer. Although several immunotherapy and targeted therapy treatments are currently under investigation, these treatments may only be effective for a subset of patients because triple-negative cancers encompass a heterogenous range of molecular profiles.
The 5-year relative survival approaches 100% for the 44% of patients with breast cancer who are diagnosed at stage I (FIGURE 4), but declines to 26% for those diagnosed with stage IV breast cancer (5% of cases). Black women are less likely than white women to be diagnosed with stage I breast cancer (34% vs 46% of cases) and have lower survival for every stage. In one study, insurance status accounted for more than one-third of the black-white disparity in breast cancer survival among nonelderly patients after adjusting for treatment differences and other clinical factors. Socioeconomic factors, comorbidities, and biological differences in cancers (eg, higher incidence of triple-negative cancers among black women) also contribute to the survival disparity.
FIGURE 4: Stage Distribution (%) by Race and Cancer Type, 2011 to 2015. Stage is based on the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 6th edition. Prostate cancer is not included because of the large proportion of missing prostate-specific antigen and/or Gleason score information for staging. Testicular cancer does not have a stage IV classification according to the AJCC Cancer Staging Manual, 6th edition. NH indicates non-Hispanic; Unk, unknown stage.
SHORT-TERM AND LONG-TERM HEALTH EFFECTS
Lymphedema of the arm occurs in 19.9% of women who undergo axillary lymph node dissection and in 5.6% of women who have a sentinel lymph node biopsy. Irradiation of the regional lymph nodes may also increase risk, particularly among patients also receiving axillary lymph node dissection. Early diagnosis of lymphedema is important for optimizing its treatment and slowing its progression. Some forms of cancer rehabilitation may reduce the risk and lessen the severity of this condition.
Other long-term local effects of surgical and radiation treatment include numbness, tingling, or tightness in the chest wall, arms, or shoulders. Recent studies suggest that approximately one-third of women develop persistent pain after breast cancer surgery or radiation therapy, with younger women and those who undergo axillary lymph node dissection having the highest risk. In addition, treatment with chemotherapy can lead to premature menopause, which increases the risk of osteoporosis and impaired fertility. Chemotherapy with taxanes often leads to neuropathy, which can persist long after treatment. Anthracyclines and HER2-targeted drugs can lead to cardiomyopathy and congestive heart failure. The American Society of Clinical Oncology recently issued guidelines for the prevention and monitoring of cardiomyopathies and other cardiovascular irregularities associated with these treatments. Treatment with aromatase inhibitors, which is generally reserved for postmenopausal women, can also cause osteoporosis as well as myalgia and arthralgia, whereas tamoxifen treatment can slightly increase the risk of endometrial cancer and thromboembolic disease. Hormonal treatments for breast cancer can also cause menopausal symptoms, such as hot flashes, night sweats, and atrophic vaginitis, which can lead to dyspareunia. Reports of sexual dysfunction are common in breast cancer survivors yet often go unaddressed. Breast cancer survivors may also experience cognitive impairments and chronic fatigue.
KEYWORDS: prevalence; statistics; survivorship; treatment patterns
PMID: 31184787
DOI: 10.3322/caac.21565
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