Petrik D W, McCready D R, Goel V, Pinfold S P, Sawka C A
Clinical Epidemiology and Health Care Research, Toronto General Hospital, Toronto, Ontario, Canada.
Breast J. 2001 May-Jun;7(3):158-65. doi: 10.1046/j.1524-4741.2001.007003158.x.
Increased emphasis on breast conservation and the primacy of the patient's preferences has led to the promotion and increased use of a two-step surgical strategy (definitive operation only after a final tissue diagnosis from a biopsy done on a previous visit) in the treatment of early breast cancer, with the assumption being that this is more conducive to the performance of breast-conserving surgery (BCS). We sought to test this by examining the effect of the surgical strategy (one-step versus two-step) on the operation performed (BCS versus mastectomy). A random sample of women with node-negative breast cancer diagnosed in 1991 in Ontario was drawn from the Ontario Cancer Registry database and matched to the Canadian Institute of Health Information and Ontario Health Insurance Plan databases (n = 643). This provided information on the timing and nature of all surgical procedures performed as well as patient, tumor, hospital, and surgeon characteristics. The surgical strategy was defined as either a one-step procedure (biopsy and definitive surgery performed at the same time) or a two-step procedure (surgical biopsy and pathologic diagnosis, followed by definitive surgery at a later date). The axillary lymph node dissection was used to define the definitive procedure. BCS was employed in 68% of patients, and this did not differ significantly between the one-step and two-step groups (66% versus 70%). Patients with palpable lesions had a significantly lower rate of breast conservation than those with nonpalpable lesions. Other variables associated with a lower rate of BCS were larger tumor size, presence of extensive ductal carcinoma in situ (DCIS), and central or multifocal tumors. The use of a one-step procedure was associated with a patient age of more than 50 years, a palpable mass, tumor size larger than 1 cm, previous fine needle aspiration (FNA) biopsy, absence of extensive DCIS, and surgery in an academic setting. Breast conservation was not affected by the surgical strategy used or the timing of the decision, but was associated with several accepted tumor factors. This study shows that, contrary to the opinion of some, there is a group of breast cancer patients in whom treatment in a one-step manner is appropriate.
对保乳治疗的日益重视以及患者偏好的首要地位，促使在早期乳腺癌治疗中推广并更多地采用两步手术策略（仅在对上一次活检进行最终组织诊断后才进行确定性手术），假定这更有利于保乳手术（BCS）的实施。我们试图通过研究手术策略（一步法与两步法）对所实施手术（BCS与乳房切除术）的影响来验证这一点。从安大略癌症登记数据库中抽取了1991年在安大略省被诊断为淋巴结阴性乳腺癌的女性随机样本，并与加拿大健康信息研究所和安大略省医疗保险计划数据库进行匹配（n = 643）。这提供了所有所实施手术的时间和性质以及患者、肿瘤、医院和外科医生特征的信息。手术策略被定义为一步法手术（活检和确定性手术同时进行）或两步法手术（手术活检和病理诊断，随后在稍后日期进行确定性手术）。腋窝淋巴结清扫术用于定义确定性手术。68%的患者接受了BCS，一步法组和两步法组之间这一比例无显著差异（66%对70%）。可触及病变的患者保乳率明显低于不可触及病变的患者。与BCS率较低相关的其他变量包括肿瘤体积较大、存在广泛导管原位癌（DCIS）以及中央或多灶性肿瘤。一步法手术的使用与患者年龄超过50岁、可触及肿块、肿瘤大小大于1 cm、既往细针穿刺（FNA）活检史以及在学术机构进行手术有关。保乳不受所采用的手术策略或决策时间的影响，但与一些公认的肿瘤因素相关。这项研究表明，与一些人的观点相反，有一组乳腺癌患者适合采用一步法治疗。
