Bordeleau L, Rakovitch E, Naimark D M, Pritchard K I, Ackerman I, Sawka C A
Toronto-Sunnybrook Regional Cancer Center, University of Toronto, Ontario, Canada.
Cancer. 2001 Jul 1;92(1):23-9. doi: 10.1002/1097-0142(20010701)92:1<23::aid-cncr1287>3.0.co;2-y.
The goals of the current study were to compare four treatment approaches in the management of ductal carcinoma in situ (DCIS), to determine the conditions where mastectomy may be preferred to breast-conserving therapy (BCT), and to determine conditions where the addition of tamoxifen produces better results than BCT alone.
A decision analysis model was used to compare four treatment approaches after local excision for DCIS: mastectomy, irradiation, irradiation plus adjuvant tamoxifen, or observation. The model weighed the potential benefits of each treatment approach (reduction of ipsilateral and/or contralateral breast carcinoma) against the potential risks of treatment-related toxicities. In addition, the model adjusted for the potential detrimental impact of local recurrence or treatment-related toxicity on health-related quality of life (HRQOL). Base-case estimates were obtained from published randomized trial data. One-way and two-way sensitivity analyses were performed.
According to the model, the optimal treatment for DCIS was strongly dependent on the individual's risk of local recurrence and the patient's attitudes toward mastectomy. Mastectomy was preferred in patients whose estimated 10-year risk of local recurrence was > 15%, provided that mastectomy resulted in a very low reduction in quality of life (i.e., utility estimate > 0.97). Conditions where the addition of tamoxifen was preferred to breast-conserving therapy alone included the following: estimated 10-year risk of local recurrence > 38%, estimated 10-year risk of developing a contralateral breast carcinoma > 6%, or a significant decrement in HRQOL associated with the development of an invasive local recurrence or salvage mastectomy (utility estimates < 0.85).
Based on this quality-adjusted model, BCT appeared to be the preferred treatment for DCIS. The most important determinants of optimal management for DCIS included the risk of local recurrence and the utility of mastectomy. Formal evaluation of utilities in the context of DCIS and more accurate determination of the risk of recurrence are required.
本研究的目的是比较导管原位癌（DCIS）治疗的四种方法，确定乳房切除术可能优于保乳治疗（BCT）的情况，以及确定添加他莫昔芬比单纯BCT产生更好结果的情况。
使用决策分析模型比较DCIS局部切除后的四种治疗方法：乳房切除术、放疗、放疗加辅助他莫昔芬或观察。该模型权衡了每种治疗方法的潜在益处（降低同侧和/或对侧乳腺癌）与治疗相关毒性的潜在风险。此外，该模型针对局部复发或治疗相关毒性对健康相关生活质量（HRQOL）的潜在不利影响进行了调整。基础病例估计值来自已发表的随机试验数据。进行了单向和双向敏感性分析。
根据该模型，DCIS的最佳治疗方法强烈依赖于个体的局部复发风险和患者对乳房切除术的态度。如果乳房切除术导致生活质量降低非常低（即效用估计>0.97），估计10年局部复发风险>15%的患者首选乳房切除术。添加他莫昔芬优于单纯保乳治疗的情况包括：估计10年局部复发风险>38%，估计10年发生对侧乳腺癌风险>6%，或与浸润性局部复发或挽救性乳房切除术相关的HRQOL显著下降（效用估计<0.85）。
基于这种质量调整模型，BCT似乎是DCIS的首选治疗方法。DCIS最佳管理的最重要决定因素包括局部复发风险和乳房切除术的效用。需要在DCIS背景下对效用进行正式评估，并更准确地确定复发风险。
