Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
J Natl Cancer Inst. 2013 Jun 5;105(11):774-81. doi: 10.1093/jnci/djt096. Epub 2013 May 3.
The prevalence of ductal carcinoma in situ (DCIS) and the marked variability in patterns of care highlight the need for comparative effectiveness research. We sought to quantify the tradeoffs among alternative management strategies for DCIS with respect to disease outcomes and breast preservation.
We developed a disease simulation model integrating data from the published literature to simulate the clinical events after six treatments (lumpectomy alone, lumpectomy with radiation, lumpectomy with radiation and tamoxifen, lumpectomy with tamoxifen, and mastectomy with and without breast reconstruction) for women with newly diagnosed DCIS. Outcomes included disease-free, invasive disease-free, and overall survival and breast preservation.
For a cohort of 1 million simulated women aged 45 years at diagnosis, both mastectomy and lumpectomy with radiation and tamoxifen were associated with a 12-month improvement in overall survival relative to lumpectomy alone. Adding radiation therapy to lumpectomy resulted in a 6-month improvement in overall survival but decreased long-term breast-preservation outcomes (likelihood of lifetime breast preservation = 0.781 vs 0.843 for lumpectomy alone). This decrement with radiation therapy was mitigated by the addition of tamoxifen (likelihood of lifetime breast preservation = 0.846).
Overall survival benefits of the six management strategies for DCIS are within 1 year, suggesting that treatment decisions can be informed by the patient's preference for breast preservation and disutility for recurrence. Our delineation of personalized outcomes for each strategy can help patients understand the implications of their treatment choice, so their decisions may reflect their own personal values and help improve the quality of care for patients with DCIS.
导管原位癌（DCIS）的患病率以及治疗模式的显著差异突出了进行比较效果研究的必要性。我们旨在针对 DCIS 的各种管理策略，定量评估其在疾病结局和乳房保留方面的权衡取舍。
我们开发了一种疾病模拟模型，该模型整合了来自已发表文献的数据，以模拟六种治疗方法（单纯乳房切除术、乳房切除术加放疗、乳房切除术加放疗和他莫昔芬、乳房切除术加他莫昔芬、乳房切除术加或不加乳房重建）后新诊断为 DCIS 的女性的临床事件。结果包括无病生存、无侵袭性疾病生存和总生存以及乳房保留。
在一个 100 万例 45 岁女性模拟队列中，与单纯乳房切除术相比，乳房切除术联合放疗和他莫昔芬以及乳房切除术与放疗均与 12 个月的总生存改善相关。与单纯乳房切除术相比，加用放疗可使总生存改善 6 个月，但会降低长期乳房保留结局（终生保留乳房的可能性=0.781 对单纯乳房切除术为 0.843）。加用他莫昔芬可减轻放疗带来的这种下降（终生保留乳房的可能性=0.846）。
六种 DCIS 管理策略的总生存获益均在 1 年内，这表明治疗决策可以基于患者对乳房保留的偏好和对复发的不适来做出。我们对每种策略的个体化结果的描述可以帮助患者了解其治疗选择的影响，以便他们的决策可以反映自己的个人价值观，并有助于提高 DCIS 患者的护理质量。
