Background

In some countries, breast cancer age-standardised mortality rates have decreased by 2–4% per year since the 1990s, but others have yet to achieve this outcome. In this study, we aimed to characterise the associations between national health system characteristics and breast cancer age-standardised mortality rate, and the degree of breast cancer downstaging correlating with national age-standardised mortality rate reductions.

Methods

In this population-based study, national age-standardised mortality rate estimates for women aged 69 years or younger obtained from GLOBOCAN 2020 were correlated with a broad panel of standardised national health system data as reported in the WHO Cancer Country Profiles 2020. These health system characteristics include health expenditure, the Universal Health Coverage Service Coverage Index (UHC Index), dedicated funding for early detection programmes, breast cancer early detection guidelines, referral systems, cancer plans, number of dedicated public and private cancer centres per 10 000 patients with cancer, and pathology services. We tested for differences between continuous variables using the non-parametric Kruskal-Wallis test, and for categorical variables using the Pearson χ² test. Simple and multiple linear regression analyses were fitted to identify associations between health system characteristics and age-standardised breast cancer mortality rates. Data on TNM stage at diagnosis were obtained from national or subnational cancer registries, supplemented by a literature review of PubMed from 2010 to 2020. Mortality trends from 1950 to 2016 were assessed using the WHO Cancer Mortality Database. The threshold for significance was set at a p value of 0·05 or less.

Findings

148 countries had complete health system data. The following variables were significantly higher in high-income countries than in low-income countries in unadjusted analyses: health expenditure (p=0·0002), UHC Index (p<0·0001), dedicated funding for early detection programmes (p=0·0020), breast cancer early detection guidelines (p<0·0001), breast cancer referral systems (p=0·0030), national cancer plans (p=0·014), cervical cancer early detection programmes (p=0·0010), number of dedicated public (p<0·0001) and private (p=0·027) cancer centres per 10 000 patients with cancer, and pathology services (p<0·0001). In adjusted multivariable regression analyses in 141 countries, two health system characteristics were significantly associated with lower age-standardised mortality rates: higher UHC Index levels (β=–0·12, 95% CI −0·16 to −0·08) and increasing numbers of public cancer centres (β=–0·23, −0·36 to −0·10). These findings indicate that each unit increase in the UHC Index was associated with a 0·12-unit decline in age-standardised mortality rates, and each additional public cancer centre per 10 000 patients with cancer was associated with a 0·23-unit decline in age-standardised mortality rate. Among 35 countries with available breast cancer TNM staging data, all 20 that achieved sustained mean reductions in age-standardised mortality rate of 2% or more per year for at least 3 consecutive years since 1990 had at least 60% of patients with invasive breast cancer presenting as stage I or II disease. Some countries achieved this reduction without most women having access to population-based mammographic screening.

Interpretation

Countries with low breast cancer mortality rates are characterised by increased levels of coverage of essential health services and higher numbers of public cancer centres. Among countries achieving sustained mortality reductions, the majority of breast cancers are diagnosed at an early stage, reinforcing the value of clinical early diagnosis programmes for improving breast cancer outcomes.

Funding

None.

中文翻译：

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国家卫生系统特征、乳腺癌诊断分期和乳腺癌死亡率：基于人群的分析

背景

在一些国家，自 1990 年代以来，乳腺癌年龄标准化死亡率每年下降 2-4%，但其他国家尚未实现这一结果。在这项研究中，我们旨在表征国家卫生系统特征与乳腺癌年龄标准化死亡率之间的关联，以及与国家年龄标准化死亡率降低相关的乳腺癌降期程度。

方法

在这项基于人群的研究中，从 GLOBOCAN 2020 获得的 69 岁或以下女性的国家年龄标准化死亡率估计值与《2020 年世卫组织癌症国家概况》中报告的广泛标准化国家卫生系统数据相关联。这些卫生系统特征包括卫生支出、全民健康覆盖服务覆盖指数（UHC 指数）、早期检测项目的专项资金、乳腺癌早期检测指南、转诊系统、癌症计划、每 10 000 名癌症患者中专门的公共和私人癌症中心的数量和病理服务。我们使用非参数 Kruskal-Wallis 检验检验了连续变量之间的差异，并使用 Pearson χ ²检验了分类变量之间的差异测试。拟合简单和多元线性回归分析以确定卫生系统特征与年龄标准化乳腺癌死亡率之间的关联。诊断时的 TNM 分期数据来自国家或国家以下癌症登记处，并辅以 2010 年至 2020 年 PubMed 的文献综述。使用 WHO 癌症死亡率数据库评估了 1950 年至 2016 年的死亡率趋势。显着性阈值设置为 0·05 或更小的 p 值。

发现

148 个国家拥有完整的卫生系统数据。在未经调整的分析中，以下变量在高收入国家明显高于低收入国家：卫生支出 (p=0·0002)、UHC 指数 (p<0·0001)、早期检测项目的专项资金 (p= 0·0020）、乳腺癌早期检测指南（p<0·0001）、乳腺癌转诊系统（p=0·0030）、国家癌症计划（p=0·014）、宫颈癌早期检测计划（p=0 ·0010）、每万名癌症患者中专门的公共（p<0·0001）和私人（p=0·027）癌症中心的数量，以及病理服务（p<0·0001）。在 141 个国家的调整后多变量回归分析中，两个卫生系统特征与较低的年龄标准化死亡率显着相关：较高的 UHC 指数水平（β=–0·12，95% CI -0·16 到 -0·08）和越来越多的公共癌症中心（β=–0·23，-0·36 到 -0·10）。这些发现表明，UHC 指数每增加一个单位，年龄标准化死亡率就会下降 0·12 个单位，而每 10 000 名癌症患者每增加一个公共癌症中心，就与 0·23 个单位下降相关年龄标准化死亡率。在拥有乳腺癌 TNM 分期数据的 35 个国家中，自 1990 年以来至少连续 3 年实现年龄标准化死亡率持续平均每年降低 2% 或更多的所有 20 个国家至少有 60% 的患者患有浸润性乳腺癌表现为 I 期或 II 期疾病。一些国家在大多数妇女无法获得基于人群的乳房 X 光检查的情况下实现了这一减少。

解释

乳腺癌死亡率低的国家的特点是基本卫生服务的覆盖水平提高，公共癌症中心的数量增加。在实现死亡率持续降低的国家中，大多数乳腺癌是在早期诊断出来的，这加强了临床早期诊断计划对改善乳腺癌结果的价值。

资金

没有任何。