Truong Pauline T, Bernstein Vanessa, Wai Elaine, Chua Boon, Speers Caroline, Olivotto Ivo A
Radiation Therapy Program, British Columbia Cancer Agency, Vancouver Island Cancer Centre, University of British Columbia, Victoria, British Columbia, Canada.
Int J Radiat Oncol Biol Phys. 2002 Nov 1;54(3):794-803. doi: 10.1016/s0360-3016(02)02973-5.
The use of axillary dissection (AD) in women with invasive breast cancer is increasingly questioned. This study analyzes the survival in women with T1-2 breast cancer according to age and AD use.
Data from the Breast Cancer Outcomes Unit Database were analyzed for 8038 women aged 50-89 years referred to the British Columbia Cancer Agency between 1989 and 1998 with invasive T1-2,M0 breast cancer. Tumor and treatment characteristics were compared between women treated with and without AD (AD+ vs. AD-) according to three age groups: 50-64, 65-74 and 75+ years. Regional relapse and actuarial 5-year overall and breast cancer-specific survival were compared between AD+ and AD- women. Multivariate analysis of age, tumor and treatment factors, and adjusted hazard ratios with AD omission were performed.
AD was omitted more frequently with advancing age (4% vs. 8% vs. 22% in women aged 50-64, 65-74, and 75+ years, respectively, p <0.0001). Tumor characteristics were more favorable in AD- women, with fewer having Grade III disease, T2 tumors, or lymphovascular invasion (all p <0.0001). Women treated without AD were also less likely to undergo radiotherapy after lumpectomy or mastectomy (both p <0.0001). Systemic therapy use and regional relapse rates were comparable between AD- and AD+ women in each age-specific cohort. Multivariate analysis identified age, tumor size, grade, lymphovascular invasion, estrogen receptor status, clinical nodal palpability, type of surgery, and radiotherapy use as independent variables affecting survival. Hazard ratios adjusted for these variables showed AD omission to be associated with lower overall survival in the entire cohort (hazard ratio 1.52, p <0.0001) and lower breast cancer-specific survival in women aged 65-74 years (hazard ratio 1.99, p = 0.02).
AD was more frequently omitted with advancing age. The lack of differences in systemic therapy use, regional relapse, and breast cancer-specific survival among AD- compared with AD+ women aged 75+ years suggests that AD use may be selectively omitted in this elderly cohort. However, the lower survival associated with AD omission among women aged 65-74 years, and the lack of a survival advantage among AD- women aged 50-64 years despite more favorable tumor characteristics and comparable systemic therapy use support the hypothesis that definitive locoregional therapy has an impact on survival.
浸润性乳腺癌女性患者腋窝淋巴结清扫术（AD）的应用越来越受到质疑。本研究根据年龄和AD的使用情况分析T1-2期乳腺癌女性患者的生存率。
分析了1989年至1998年间转诊至不列颠哥伦比亚癌症机构的8038例年龄在50-89岁之间的T1-2、M0期浸润性乳腺癌女性患者的乳腺癌结局单位数据库数据。根据三个年龄组：50-64岁、65-74岁和75岁及以上，比较接受和未接受AD治疗的女性（AD+组与AD-组）的肿瘤和治疗特征。比较AD+组和AD-组女性的区域复发情况以及精算5年总生存率和乳腺癌特异性生存率。对年龄、肿瘤和治疗因素进行多变量分析，并计算省略AD后的调整风险比。
随着年龄增长，AD的省略更为频繁（50-64岁、65-74岁和75岁及以上女性中分别为4%、8%和22%，p<0.0001）。AD-组女性的肿瘤特征更有利，III级疾病、T2肿瘤或淋巴管浸润的患者较少（均p<0.0001）。未接受AD治疗的女性在保乳手术或乳房切除术后接受放疗的可能性也较小（均p<0.0001）。在每个年龄特定队列中，AD-组和AD+组女性的全身治疗使用情况和区域复发率相当。多变量分析确定年龄、肿瘤大小、分级、淋巴管浸润、雌激素受体状态、临床可触及淋巴结、手术类型和放疗使用是影响生存的独立变量。针对这些变量调整后的风险比显示，省略AD与整个队列中较低的总生存率相关（风险比1.52，p<0.0001），在65-74岁女性中与较低的乳腺癌特异性生存率相关（风险比1.99，p=0.02）。
随着年龄增长，AD的省略更为频繁。75岁及以上接受AD-治疗与AD+治疗的女性在全身治疗使用、区域复发和乳腺癌特异性生存率方面缺乏差异，这表明在这个老年队列中可以选择性地省略AD。然而，65-74岁女性中省略AD与较低的生存率相关，50-64岁接受AD-治疗的女性尽管肿瘤特征更有利且全身治疗使用情况相当但缺乏生存优势，这支持了确定性局部区域治疗对生存有影响的假设。
