veruse of cesarean delivery can jeopardize maternal and child health. 1,2 Concerns about "alarming" 3 rates in China increased after the World Health Organization (WHO) 4 reported that 46.2% of births were delivered by cesarean in the years 2007 and 2008, based on an analysis of 14 541 deliveries in 21 hospitals in 3 provinces. With a population of approximately 1.37 billion in 2014, China's health care use is of substantial global interest. Over the past 2 decades, the nation has invested in improving maternal and child health. The Law on Maternal and Infant Health Care was passed in 1995 to provide a high-quality hospital delivery to all women. 5 Health insurance expansion began in 2003, to provide better financial access to maternity care. 6 In 2009, a comprehensive health care reform plan included subsidies for in-hospital delivery to pregnant women in rural areas. 7 In 2008, 89.9% of deliveries occurred in hospitals, and 87.9% of families had health insurance. 6 By 2014, 99.6% of deliveries occurred in hospitals. 8 China's increasing cesarean rate has been spurred by many factors, including expanded access to hospital care, medicolegal concerns, financial incentives for physicians to perform cesareans, and parents' focus on having a "perfect baby" under the one-child policy. 9,10 Since 2002, reducing the cesarean rate has been a national priority, 11 and a variety of policies, programs, and activities have emerged at the central government, 12 provincial or municipal, 13 city, 14 and city district or county levels. 15 There is no national IMPORTANCE The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. OBJECTIVE To provide updated information about cesarean rates and geographic variation in cesarean use in China. DESIGN, SETTING, AND DATA SOURCES Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. EXPOSURES Live births. MAIN OUTCOMES AND MEASURES Annual rate of cesarean deliveries. RESULTS Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. CONCLUSIONS AND RELEVANCE Between 2...
Although many studies have investigated intensity-modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC), sample sizes in the reported studies are usually small and different in outcomes in different T and N subgroups are seldom analyzed. Herein, we evaluated the outcomes of NPC patients treated with IMRT and further explored treatment strategy to improve such outcome. We collected clinical data of 865 NPC patients treated with IMRT alone or in combination with chemotherapy, and classified all cases into the following prognostic categories according to different TNM stages: early stage group (T1–2N0–1M0), advanced local disease group (T3–4N0–1M0), advanced nodal disease group (T1–2N2–3M0), and advanced locoregional disease group (T3–4N2–3M0). The 5-year overall survival (OS), local relapse-free survival (LRFS), and distant metastases-free survival (DMFS) were 83.0%, 90.4%, and 84.0% respectively. The early disease group had the lowest treatment failure rate, with a 5-year OS of 95.6%. The advanced local disease group and advanced nodal disease group had similar failure pattern and treatment outcomes as well as similar hazard ratios for death (4.230 and 4.625, respectively). The advanced locoregional disease group had the highest incidence of relapse and death, with a 5-year DMFS and OS of 62.3% and 62.2%, respectively, and a hazard ratio for death of 10.402. Comparing with IMRT alone, IMRT in combination with chemotherapy provided no significant benefit to locoregionally advanced NPC. Our results suggest that the decision of treatment strategy for NPC patients should consider combinations of T and N stages, and that IMRT alone for early stage NPC patients can produce satisfactory results. However, for advanced local, nodal, and locoregional disease groups, a combination of chemotherapy and radiotherapy is recommended.
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