Van de Steene J, Soete G, Storme G
Department of Radiotherapy, Oncology Centre AZ-VUB, Academic Hospital, Free University Brussels, Laarbeeklaan 101, Jette-Brussels, Belgium.
Radiother Oncol. 2000 Jun;55(3):263-72. doi: 10.1016/s0167-8140(00)00204-8.
The influence of surgical adjuvant radiotherapy on overall survival of patients with operable breast cancer is still a controversial subject. The negative result of the EBCTCG meta-analysis (Early breast cancer trialists', collaborative group. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomised trials. N. Engl. J. Med. 1995;333:1444-1455) of clinical randomized trials on adjuvant radiotherapy in breast cancer is in strong contrast with the Danish 82B, 82C and British Columbia trials (Overgaard M, Hanse PS, Overgaar J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N. Engl. J. Med. 1997;337:949-955; Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomized trial. Lancet 1999;353:1641-1648; Ragaz J, Jackson S, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N. Engl. J. Med. 1997;337:956-962) showing an impressive survival benefit. This paper tries to fill in the gap between the conflicting results.
The 36 trials of the EBCTCG (Early breast cancer trialists', collaborative group, 1995) were prospectively screened for a number of objective parameters that are usually not analyzed in review papers. The odds of death data (and its variance) were borrowed from the original meta-analysis (Early breast cancer trialists', collaborative group, 1995) to check whether the objective features were significant predictors for overall survival benefit.
A significant survival benefit for the radiotherapy arm was found for recent trials (2P<0.05), large trials (2P<0.03), trials that used standard fractionation (2P<0.02), and trials with a favourable crude survival (2P<0.03). For these four parameters clear parameter-effect relations were found. In recent and large trials the odds reduction was 12.4% (2P=0.004).
Surgical adjuvant radiotherapy significantly improves overall survival of breast cancer patients provided that current techniques are used and treatment is given with standard fractionation. For the best subgroups we observed an odds of death reduction of more than 20%. The results of this study stress the importance of reducing cardiovascular and other late toxicity in adjuvant radiotherapy for breast cancer.
手术辅助放疗对可手术乳腺癌患者总生存期的影响仍是一个有争议的话题。早期乳腺癌协作组（EBCTCG）对乳腺癌辅助放疗的临床随机试验进行的荟萃分析（早期乳腺癌试验者协作组。放疗与手术对早期乳腺癌的影响。随机试验综述。《新英格兰医学杂志》1995年；333:1444 - 1455）的阴性结果与丹麦82B、82C试验及不列颠哥伦比亚试验（奥弗加德M，汉泽PS，奥弗加德J等。接受辅助化疗的高危绝经前乳腺癌女性术后放疗。丹麦乳腺癌协作组82b试验。《新英格兰医学杂志》1997年；337:949 - 955；奥弗加德M，延森MB，奥弗加德J等。接受辅助他莫昔芬治疗的高危绝经后乳腺癌患者术后放疗：丹麦乳腺癌协作组DBCG 82c随机试验。《柳叶刀》1999年；353:1641 - 1648；拉加兹J，杰克逊S，勒N等。淋巴结阳性绝经前乳腺癌女性辅助放疗与化疗。《新英格兰医学杂志》1997年；337:956 - 962）形成强烈对比，后者显示出显著的生存获益。本文试图填补这一相互矛盾结果之间的空白。
对EBCTCG（早期乳腺癌试验者协作组，1995年）的36项试验进行前瞻性筛选，以获取一些通常在综述文章中未分析的客观参数。从原始荟萃分析（早期乳腺癌试验者协作组，1995年）中借用死亡比值数据（及其方差），以检验这些客观特征是否为总生存获益的显著预测因素。
对于近期试验（P<0.05）、大型试验（P<0.03）、采用标准分割的试验（P<0.02）以及粗生存率良好的试验（P<0.03），放疗组有显著的生存获益。对于这四个参数，发现了明确的参数 - 效应关系。在近期和大型试验中，死亡比值降低了12.4%（P = 0.004）。
只要采用当前技术并进行标准分割治疗，手术辅助放疗可显著提高乳腺癌患者的总生存期。对于最佳亚组，我们观察到死亡比值降低超过20%。本研究结果强调了在乳腺癌辅助放疗中降低心血管及其他晚期毒性的重要性。
