Kingsmore D, Ssemwogerere A, Hole D, Gillis C
University Department of Surgery, Western Infirmary, Dumbarton Road, Glasgow G11 6NT, UK.
Br J Cancer. 2003 Jun 2;88(11):1708-12. doi: 10.1038/sj.bjc.6600949.
It is recommended that specialist surgeons treat all breast cancer, although the limited evidence to support this is based on treatment patterns prior to the introduction of screening. Whether a specialist survival advantage exists in the post-screening era is uncertain, as referral and treatment patterns may have changed, in addition to the effect of screening on the natural history of breast cancer. Our aim was to determine the impact of screening on the caseload and case-mix of specialist surgeons, to determine if the survival advantage associated with specialist care is maintained with longer follow-up and persists after the introduction of screening. Using the West of Scotland Cancer Registry, all 7197 women treated for breast cancer in a 15-year time period (1980-1994) in a geographically defined cohort were followed up for an average of 9 years, and pathological stage and socioeconomic status were linked with mortality data. We show that the caseload of specialists has increased substantially (from 11 to 59% of the total workload) and that smaller cancers have been selectively referred. However, even after allowing for pathological stage, socioeconomic status and method of detection, specialist treatment was associated with a significantly lower risk of dying (prescreening: relative risk of dying=0.83, 95% CI=0.75-0.92; post-screening: relative risk of dying=0.89, 95% CI=0.78-1.00). We conclude that this survival benefit is most consistent with effective surgical management rather than selective referral, the influx of screen-detected cancers or adjuvant therapies.
建议由专科外科医生治疗所有乳腺癌患者，尽管支持这一建议的证据有限，且这些证据是基于筛查引入之前的治疗模式。在筛查时代之后，专科治疗是否具有生存优势尚不确定，因为除了筛查对乳腺癌自然病程的影响外，转诊和治疗模式可能已经发生了变化。我们的目的是确定筛查对专科外科医生的工作量和病例组合的影响，确定与专科护理相关的生存优势在更长时间的随访中是否得以维持，以及在筛查引入后是否仍然存在。利用苏格兰西部癌症登记处的数据，对在一个地理区域界定的队列中15年期间（1980 - 1994年）接受乳腺癌治疗的7197名女性进行了平均9年的随访，并将病理分期和社会经济状况与死亡率数据相关联。我们发现专科医生的工作量大幅增加（从总工作量的11%增至59%），且较小的癌症患者被选择性转诊。然而，即使考虑到病理分期、社会经济状况和检测方法，专科治疗与死亡风险显著降低相关（筛查前：死亡相对风险 = 0.83，95%置信区间 = 0.75 - 0.92；筛查后：死亡相对风险 = 0.89，95%置信区间 = 0.78 - 1.00）。我们得出结论，这种生存获益最符合有效的手术管理，而非选择性转诊、筛查发现的癌症患者涌入或辅助治疗。
