恶性胸膜间皮瘤治疗的国家指南遵循情况存在差异。
Disparities in Compliance With National Guidelines for the Treatment of Malignant Pleural Mesothelioma.
机构信息
Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, California.
出版信息
Ann Thorac Surg. 2019 Sep;108(3):889-896. doi: 10.1016/j.athoracsur.2019.03.052. Epub 2019 Apr 18.
BACKGROUND
Current guidelines support cancer-directed surgery, chemotherapy, or active surveillance for clinical stages 1 to 3 of epithelial malignant pleural mesothelioma (MPM). Definitive chemotherapy is recommended for sarcomatoid/biphasic histologies. Our objective is to assess compliance with recommendations, measuring their impact on overall survival.
METHODS
The National Cancer Database participant user file (2004 to 2014) was queried for patients diagnosed with MPM clinical stages 1 to 3. Multivariable logistic regression model identified factors independently associated with guideline compliance. Kaplan-Meier analysis and Cox proportional hazards were used for overall survival comparison with histologic subgroup analysis.
RESULTS
A total of 3419 patients with clinical stages 1 to 3 met criteria for analysis and comprised epithelial (68.5%), sarcomatoid (17.2%), and biphasic subtypes (14.3%). Cancer-directed surgery was significantly underutilized in epithelial MPM, with 29.3% having no treatment. On multivariable analysis, insurance status and facility type were the strongest predictors of guideline compliance. High-volume hospitals were the most compliant with guidelines (odds ratio 3.58, 95% confidence interval (CI), 2.34 to 5.49, P < .001). Median survival estimates for no treatment, chemotherapy alone, surgery plus chemotherapy, and trimodal therapy were 10.2, 15.4, 21.1, and 21.7 months, respectively (log rank P < .001). In epithelial MPM, a significant increase in overall survival was observed in surgery plus chemotherapy (hazard ratio 0.62, 95% CI, 0.53 to 0.73, P < .001) and trimodality (hazard ratio 0.61, 95% CI, 0.49 to 0.76, P < .001; reference: no treatment).
CONCLUSIONS
There is a suboptimal compliance with national guidelines for the treatment of MPM, particularly in low-volume nonacademic settings. Adherence to recommended surgery-based multimodal therapy is associated with an overall survival improvement.
背景
目前的指南支持对上皮性恶性胸膜间皮瘤（MPM）临床分期 1 至 3 期进行以癌症为导向的手术、化疗或主动监测。对于肉瘤样/双相组织学类型，建议进行确定性化疗。我们的目的是评估对建议的遵守情况，衡量其对总生存期的影响。
方法
从 2004 年至 2014 年，查询国家癌症数据库参与者用户文件，以确定诊断为 MPM 临床分期 1 至 3 期的患者。多变量逻辑回归模型确定与指南遵守独立相关的因素。采用 Kaplan-Meier 分析和 Cox 比例风险模型进行总体生存比较，并进行组织学亚组分析。
结果
共有 3419 名临床分期 1 至 3 期的患者符合分析标准，包括上皮性（68.5%）、肉瘤样（17.2%）和双相性亚型（14.3%）。上皮性 MPM 中以癌症为导向的手术明显未得到充分利用，有 29.3%的患者未接受任何治疗。多变量分析显示，保险状况和医疗机构类型是指南遵守的最强预测因素。高容量医院最符合指南（优势比 3.58，95%置信区间（CI）为 2.34 至 5.49，P<0.001）。无治疗、单独化疗、手术加化疗和三联疗法的中位生存估计分别为 10.2、15.4、21.1 和 21.7 个月（对数秩检验 P<0.001）。在上皮性 MPM 中，手术加化疗（风险比 0.62，95%CI，0.53 至 0.73，P<0.001）和三联疗法（风险比 0.61，95%CI，0.49 至 0.76，P<0.001；参考：无治疗）的总生存均显著提高。
结论
在 MPM 的治疗中，国家指南的遵守情况并不理想，尤其是在低容量非学术环境中。遵守推荐的以手术为基础的多模式治疗与总生存期的改善相关。
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