Kuo Kelly, Caughey Aaron B
a Department of Obstetrics and Gynecology , Oregon Health & Science University , Portland , OR , USA.
J Matern Fetal Neonatal Med. 2019 Feb;32(3):419-428. doi: 10.1080/14767058.2017.1381900. Epub 2017 Sep 27.
To compare strategies for the timing of delivery in women with breast cancer and known cancer stage or hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes.
A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of the stage- and subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate sensitivity analyses and Monte Carlo simulations were performed to test the robustness of our model.
For women with stage I-II breast cancer, delivery at 36 weeks yielded the highest number of overall quality-adjusted life years (QALYs), while maternal QALYs were maximized with delivery at 34 weeks. For stage III and IV disease, maternal QALYs were maximized at 31 and 30 weeks, respectively. For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative breast cancer, both maternal QALYs and overall QALYs were maximized with delivery at 36 weeks. More aggressive biological phenotypes were similarly associated with optimal delivery at decreasing gestational age. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decreases in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest.
For women with breast cancer diagnosed during pregnancy, decisions regarding timing of delivery should take into consideration both cancer stage and hormone receptor subtype.
比较已知癌症分期或激素受体亚型的乳腺癌女性的分娩时机策略，并确定就母婴结局而言引产的最佳孕周。
设计了一个决策分析模型，比较在妊娠30、31、32、33、34、35、36和37周计划分娩的八种不同策略。假定最佳乳腺癌治疗推迟至分娩后进行。从文献中获取特定分期和亚型的死亡率基线估计值以及延迟癌症治疗对5年生存率的影响。纳入模型的结局因素包括每个孕周的宫内胎儿死亡、自然分娩、呼吸窘迫综合征、脑瘫和新生儿死亡风险。进行单因素敏感性分析和蒙特卡洛模拟以检验模型的稳健性。
对于I-II期乳腺癌女性，36周分娩产生的总体质量调整生命年（QALY）数量最高，而34周分娩时母亲的QALY最大化。对于III期和IV期疾病，母亲的QALY分别在31周和30周时最大化。对于雌激素或孕激素受体阳性、人表皮受体-2阴性乳腺癌女性，36周分娩时母亲的QALY和总体QALY均最大化。更具侵袭性的生物学表型同样与在降低的孕周时最佳分娩相关。除了疾病的预期进展以及每延迟一周治疗生存率的下降之外，我们的模型还受到母亲5年内死亡的基线概率的严重驱动，并且在所有感兴趣变量的合理范围内均保持稳健。
对于孕期诊断为乳腺癌的女性，关于分娩时机的决策应同时考虑癌症分期和激素受体亚型。
