Lin Heather Y, Bedrosian Isabelle, Babiera Gildy V, Shaitelman Simona F, Kuerer Henry M, Woodward Wendy A, Ueno Naoto T, Shen Yu
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Cancer. 2017 Jul 15;123(14):2618-2625. doi: 10.1002/cncr.30660. Epub 2017 Mar 13.
Guidelines for the treatment of nonmetastatic inflammatory breast cancer (IBC) using trimodality therapy (TT) (chemotherapy, surgery, and radiotherapy) have remained largely unchanged since 2000. However, many patients with nonmetastatic IBC do not receive TT. It is unknown how patient-level (PL) and facility-level (FL) factors contribute to TT use.
Using the National Cancer Data Base, patients with nonmetastatic IBC who underwent locoregional treatment from 2003 through 2011 were identified. The authors correlated PL factors, including demographic and tumor characteristics, with TT use. An observed-to-expected ratio for the number of patients treated with TT was calculated for each hospital by adjusting for significant PL factors. Hierarchical mixed effects models were used to assess the percentage of variation in TT use attributable to PL and FL factors, respectively.
Of the 542 hospitals examined, 55 (10.1%) and 24 (4.4%), respectively, were identified as significantly low and high outliers for TT use (P<.05). The percentage of the total variance in the use of TT attributable to the facility (11%) was nearly triple the variance attributable to the measured PL factors (3.4%). The nomogram generated from multivariate logistic regression of PL factors only allows a facility to assess TT use given their PL data.
FL factors rather than PL factors appear to contribute disproportionately to the underuse of TT in patients with nonmetastatic IBC. To improve treatment guideline adherence for patients with nonmetastatic IBC, it is critical to identify the specific FL factors associated with TT underuse. More organized FL intervention is required to train physicians and to build multidisciplinary teams. Cancer 2017;123:2618-25. © 2017 American Cancer Society.
自2000年以来，使用三联疗法（TT）（化疗、手术和放疗）治疗非转移性炎性乳腺癌（IBC）的指南基本保持不变。然而，许多非转移性IBC患者未接受TT治疗。目前尚不清楚患者层面（PL）和机构层面（FL）的因素如何影响TT的使用。
利用国家癌症数据库，确定了2003年至2011年接受局部区域治疗的非转移性IBC患者。作者将包括人口统计学和肿瘤特征在内的PL因素与TT的使用情况进行了关联。通过调整显著的PL因素，计算了每家医院接受TT治疗的患者数量的观察值与预期值之比。采用分层混合效应模型分别评估PL和FL因素导致TT使用差异的百分比。
在所检查的542家医院中，分别有55家（10.1%）和24家（4.4%）被确定为TT使用的显著低异常值和高异常值（P<0.05）。机构因素导致TT使用差异的总方差百分比（11%）几乎是所测量的PL因素导致的方差百分比（3.4%）的三倍。仅根据PL因素进行多变量逻辑回归生成的列线图，可让机构根据其PL数据评估TT的使用情况。
对于非转移性IBC患者，TT使用不足似乎更多是由FL因素而非PL因素导致的。为提高非转移性IBC患者对治疗指南的依从性，识别与TT使用不足相关的具体FL因素至关重要。需要更有组织的FL干预来培训医生并建立多学科团队。《癌症》2017年；123:2618 - 25。©2017美国癌症协会
