Department of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware Street S.E. MMC 729, Minneapolis, MN 55455, USA.
Breast Cancer Res Treat. 2010 Nov;124(2):393-402. doi: 10.1007/s10549-010-1166-7. Epub 2010 Sep 17.
To integrate margin status information into the decision to undergo radiation therapy (RT) following breast-conserving surgery (BCS) for women with ductal carcinoma in situ (DCIS). We developed a decision-analytic Markov model to project quality-adjusted life years (QALYs) for a hypothetical cohort of 55-year-old women with DCIS over a lifetime horizon treated with or without RT following BCS. We estimated the transition probabilities of local DCIS and invasive recurrences based on the margin status (free, close, or positive) from a systematic literature review. Other probability estimates and utilities were collected from the published literature. Using the conditions defined in this model, expected QALYs after BCS alone were better than those after BCS with RT under the free-margin scenario (15.72 vs. 15.58) and worse in the close-margin (15.44 vs. 15.50) and positive-margin scenarios (15.20 vs. 15.33). The probability of receiving a salvage mastectomy varied from 10 to 28%, depending on margin status and treatment. One-way sensitivity analyses showed that the optimal treatment was sensitive to patients' preferences and RT side effects. Probabilistic sensitivity analyses revealed that BCS alone would be the best strategy in 54% of the cases under the free-margin scenario, 48% under the close-margin scenario, and 44% under the positive-margin scenario. This study illustrates that margin status is able to provide supplementary information on the decision of DCIS treatment. Our analyses also highlight the importance of patients' preferences in decision making. Our findings suggest that RT is not necessary for all patients with DCIS undergoing BCS.
将边缘状态信息整合到保乳手术后（BCS）行放射治疗（RT）的决策中，以治疗导管原位癌（DCIS）患者。我们开发了一个决策分析马尔可夫模型，以预测在一生中接受或不接受 BCS 后 RT 治疗的 55 岁 DCIS 假设队列的质量调整生命年（QALY）。我们根据系统文献回顾中边缘状态（无、近切缘或阳性）来估计局部 DCIS 和侵袭性复发的转移概率。其他概率估计和效用从已发表的文献中收集。使用该模型中定义的条件，在无边缘状态下，BCS 后单独接受治疗的预期 QALY 优于 BCS 后联合 RT 治疗的预期 QALY（15.72 比 15.58），在近切缘状态（15.44 比 15.50）和阳性边缘状态下更差（15.20 比 15.33）。根据边缘状态和治疗情况，接受挽救性乳房切除术的概率从 10%到 28%不等。单因素敏感性分析表明，最佳治疗方案对患者偏好和 RT 副作用敏感。概率敏感性分析表明，在无边缘状态下，54%的病例中 BCS 单独治疗是最佳策略，在近切缘状态下为 48%，在阳性边缘状态下为 44%。这项研究表明，边缘状态能够为 DCIS 治疗决策提供补充信息。我们的分析还强调了患者偏好在决策中的重要性。我们的研究结果表明，并非所有接受 BCS 的 DCIS 患者都需要接受 RT。
