Alarid-Escudero Fernando, Blaes Anne H, Kuntz Karen M
Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.
Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
Breast J. 2017 Jul;23(4):401-409. doi: 10.1111/tbj.12757. Epub 2017 Jan 24.
Evidence about treatment efficacy and long-term toxicities for adjuvant chemotherapy in patients with early-stage breast cancer is often presented in different formats and studies. This leads to challenges for patients and their physicians to adequately weigh the trade-offs between effectiveness and long-term cardiac toxicity when making decisions about adjuvant chemotherapy. We used a decision-analytic framework to quantify these trade-offs by combining the available evidence into a single, comparable metric. We developed a Markov model to simulate a hypothetical cohort of newly diagnosed breast cancer patients under three scenarios: no treatment, anthracycline (AC)-based adjuvant chemotherapy (more effective but also more cardiotoxic), and non-AC-based adjuvant chemotherapy. We derived the model parameters from medical literature (e.g., clinical trials). Our primary outcome is 10-year mortality, and other metrics such as cause of death; life years (LYs) and quality-adjusted LYs over 10 years were evaluated in sensitivity analysis. For 55-year-old women with a 10-year risk of metastatic recurrence <12.5% no chemotherapy resulted in the preferred strategy. In general, non-AC-based adjuvant chemotherapy resulted in lower 10-year mortality than AC-based chemotherapy. Patients with low risk of metastatic recurrence are better off without adjuvant chemotherapy regardless of the outcome considered (i.e., the risks of cardiac toxicity from chemotherapy outweighed the benefits). Trade-offs between effectiveness and induced cardiac toxicity impact health outcomes. The choice of adjuvant treatment must consider the patient's risk of distant recurrence and the quality of life associated with different health outcomes.
关于早期乳腺癌患者辅助化疗的治疗效果和长期毒性的证据，通常以不同的形式呈现于不同的研究中。这给患者及其医生在决定辅助化疗时充分权衡疗效与长期心脏毒性之间的利弊带来了挑战。我们使用了一个决策分析框架，通过将现有证据整合为一个单一的、可比较的指标来量化这些利弊。我们开发了一个马尔可夫模型，以模拟一组新诊断的乳腺癌患者在三种情况下的情况：不治疗、基于蒽环类药物（AC）的辅助化疗（更有效但心脏毒性也更大）和非AC辅助化疗。我们从医学文献（如临床试验）中得出模型参数。我们的主要结果是10年死亡率，在敏感性分析中还评估了其他指标，如死亡原因；10年的生命年数（LYs）和质量调整生命年数。对于转移性复发10年风险<12.5%的55岁女性，不进行化疗是首选策略。一般来说，非AC辅助化疗导致的10年死亡率低于基于AC的化疗。无论考虑何种结果（即化疗引起的心脏毒性风险超过益处），转移性复发风险低的患者不进行辅助化疗情况更好。疗效与诱导的心脏毒性之间的权衡会影响健康结果。辅助治疗的选择必须考虑患者远处复发的风险以及与不同健康结果相关的生活质量。
