Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Ann Surg Oncol. 2020 Sep;27(9):3426-3433. doi: 10.1245/s10434-020-08388-8. Epub 2020 Mar 25.
In the past two decades, three prospective randomized trials demonstrated that elderly women with early stage hormone positive breast cancer had equivalent disease-specific mortality regardless of axillary surgery. In 2016, the Choosing Wisely campaign encouraged patients and providers to reconsider the role of axillary surgery in this population. We sought to identify factors that contribute to adopting non-operative management of the axilla in these patients.
We performed a retrospective analysis of women ≥ 70 years old with cT1/T2, hormone positive invasive ductal carcinoma who underwent partial or total mastectomy, with/without axillary surgery, and did not receive adjuvant chemotherapy from the National Cancer Database from 2004 to 2015. We used multivariable log-binomial regression to model the risk of undergoing axillary surgery across region, care setting, and Charlson-Deyo scores, and analyzed temporal trends using Poisson regression. From 2004 to 2015, 87,342 of 99,940 women who met inclusion criteria (83%) had axillary surgery. Over time, axillary surgery increased from 78% to 88% (p < 0.001). This rise was consistent across region (p = 0.81) and care setting (p = 0.09), but flattened as age increased (p < 0.001). Omitting axillary surgery was more likely in patients treated in New England (RR 0.88, 95% CI 0.86, 0.89) and patients ≥ 85 (RR 0.66, 95% CI 0.65, 0.67).
Axillary surgery continues to be the preferred option of axillary management in elderly women with early stage, clinically node negative, hormone-positive, invasive breast cancer despite no survival benefit. Identifying factors to improve patient selection and dissemination of current recommendations can improve adoption of current evidence on axillary surgery in the elderly.
在过去的二十年中，三项前瞻性随机试验表明，患有早期激素阳性乳腺癌的老年女性无论是否接受腋窝手术，其疾病特异性死亡率均相当。2016 年，明智选择运动鼓励患者和医务人员重新考虑在该人群中腋窝手术的作用。我们试图确定导致这些患者采用非手术方式管理腋窝的因素。
我们对 2004 年至 2015 年期间，国家癌症数据库中年龄≥70 岁、患有 cT1/T2 激素阳性浸润性导管癌、行部分或全乳房切除术、伴或不伴腋窝手术且未接受辅助化疗的女性进行了回顾性分析。我们使用多变量二项式回归模型来分析区域、护理环境和 Charlson-Deyo 评分对接受腋窝手术的风险，并使用泊松回归分析时间趋势。2004 年至 2015 年，符合纳入标准的 99,940 名女性中有 87,342 名（83%）接受了腋窝手术。随着时间的推移，腋窝手术的比例从 78%增加到 88%（p<0.001）。这种上升在各地区（p=0.81）和护理环境（p=0.09）中是一致的，但随着年龄的增长而趋于平稳（p<0.001）。在新英格兰地区（RR 0.88，95%CI 0.86，0.89）和≥85 岁的患者（RR 0.66，95%CI 0.65，0.67）中，省略腋窝手术的可能性更大。
尽管对生存没有获益，但在患有早期临床淋巴结阴性、激素阳性、浸润性乳腺癌的老年女性中，腋窝手术仍然是首选的腋窝管理方法。确定可以改善患者选择和当前腋窝手术推荐意见传播的因素，有助于提高对老年人腋窝手术的当前证据的采用。
