J Natl Cancer Inst. 2019 Sep 1;111(9):903-915. doi: 10.1093/jnci/djz105.
In early breast cancer treatment, the preferred surgical regimen remains a topic of controversy, and conventional pairwise meta-analysis cannot provide a hierarchy based on clinical trial evidence. Therefore, a network meta-analysis was performed both for direct and indirect comparisons and to assess the survival outcomes of surgical regimens.
Randomized clinical trials comparing different surgical regimens for the treatment of early breast cancer were identified. Overall survival (OS) and disease-free-survival (DFS) were analyzed using random-effects network meta-analysis on the hazard ratio (HR) scale and calculated as combined HRs and 95% confidence intervals (CIs). All statistical tests were two-sided.
The network meta-analysis compared 11 different surgical regimens that consisted of 13 and 17 direct comparisons between strategies for OS (34 trials; n = 23 587 patients) and DFS (32 trials; n = 22 552 patients), respectively. The values of surface under the cumulative ranking for OS and DFS after mastectomy (M)+radiotherapy (RT) were observed to be the largest. Breast-conserving surgery (BCS)+axillary node sampling+RT almost achieved the threshold for inferiority compared with the other surgical treatment arms and was statistically significantly associated with worse OS (HR = 0.51, 95% CI = 0.24 to 0.94; HR = 0.48, 95% CI = 0.22 to 0.92; HR = 0.51, 95% CI = 0.23 to 0.96). No statistically significant difference between BCS+sentinel lymph node biopsy (SLNB)+RT vs BCS+SLNB+intraoperative RT was observed in carrying out network meta-analysis (HR = 0.95, 95% CI = 0.64 to 1.36).
M+RT has the most favorable survival outcomes among the various surgical regimens for the treatment of early breast cancer patients. For patients who receive BCS, SNLB has more favorable outcomes than axillary node sampling. Intraoperative RT and postoperative RT have similar outcomes in patients who receive SLNB.
在早期乳腺癌治疗中，首选的手术方案仍然存在争议，传统的两两荟萃分析无法基于临床试验证据提供一个等级。因此，我们进行了网络荟萃分析，同时进行了直接和间接比较，并评估了手术方案的生存结局。
我们检索了比较不同手术方案治疗早期乳腺癌的随机临床试验。使用随机效应网络荟萃分析对风险比（HR）进行了总体生存（OS）和无病生存（DFS）分析，并计算了合并 HR 和 95%置信区间（CI）。所有统计检验均为双侧。
网络荟萃分析比较了 11 种不同的手术方案，这些方案包括 13 种 OS（34 项试验；n=23587 例患者）和 17 种 DFS（32 项试验；n=22552 例患者）的直接比较。在乳房切除术（M）+放疗（RT）后，OS 和 DFS 的累积排序概率面积值最大。保乳手术（BCS）+腋窝淋巴结采样+RT 与其他手术治疗组相比，几乎达到了劣势的阈值，并且与 OS 较差显著相关（HR=0.51，95%CI=0.24 至 0.94；HR=0.48，95%CI=0.22 至 0.92；HR=0.51，95%CI=0.23 至 0.96）。在进行网络荟萃分析时，BCS+前哨淋巴结活检（SLNB）+术中 RT 与 BCS+SLNB+术后 RT 之间未观察到统计学显著差异（HR=0.95，95%CI=0.64 至 1.36）。
在各种治疗早期乳腺癌患者的手术方案中，M+RT 的生存结局最好。对于接受 BCS 的患者，SLNB 比腋窝淋巴结采样的结局更好。对于接受 SLNB 的患者，术中 RT 和术后 RT 的结局相似。
