跨越乳腺癌的年龄差距。雌激素受体阳性早期乳腺癌老年女性中省略乳腺癌手术的影响。生存结局和生活质量的风险分层分析。
Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life.
机构信息
Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
Brighton and Sussex Medical School, Falmer, Brighton, UK.
出版信息
Eur J Cancer. 2021 Jan;142:48-62. doi: 10.1016/j.ejca.2020.10.015. Epub 2020 Nov 18.
BACKGROUND
Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET.
METHODS
Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET.
FINDINGS
A total of 3416 women (median age 77, range 69-102) were recruited from 56 breast units-2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23-0.33, P < 0.001). Unmatched breast cancer-specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29-0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53-0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40-1.37, P = 0.34) although at 4-5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance.
INTERPRETATION
For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4-5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/).
TRIAL REGISTRATION NUMBER
ISRCTN: 46099296.
背景
与许多老年女性接受主要内分泌治疗（PET）相关的乳腺癌治疗差异普遍存在，这可能导致生存和局部控制情况较差。本倾向评分匹配研究旨在确定是否可以安全地为一部分老年女性提供 PET。
方法
这是一项多中心、前瞻性、英国观察队列研究，采用倾向评分匹配分析，以确定≥ 70 岁患有乳腺癌的女性中，手术加内分泌治疗（S+ET）或 PET 的最佳分配。收集了关于健康状况、虚弱、癌症分期、分级、生物型、治疗和生活质量的数据。倾向评分匹配（基于年龄、健康状况和癌症分期）在比较 S+ET 与 PET 时调整了分配偏差。
结果
共招募了 3416 名年龄在 69-102 岁（中位年龄 77 岁）的女性，来自 56 个乳腺单位 - 2854 名（88%）患有 ER+乳腺癌：2354 名接受 S+ET，500 名接受 PET。中位随访时间为 52 个月。与接受 S+ET 的患者相比，接受 PET 的患者年龄更大且更虚弱。PET 组的总生存率（HR：0.27，95%置信区间（CI）：0.23-0.33，P<0.001）较差。接受 PET 治疗的患者的乳腺癌特异性生存率（BCSS）也较差（HR：0.41，95%CI：0.29-0.58，P<0.001）。在匹配分析中，PET 仍然与较差的总体生存率相关（HR：0.72，95%CI：0.53-0.98，P=0.04），但与 BCSS 无关（HR：0.74，95%CI：0.40-1.37，P=0.34），尽管在 4-5 年内，手术的生存优势开始显现。在某些时间点，两组的总体健康状况存在差异，但在调整基线差异后，在 24 个月内相似。
解释
对于大多数患有早期 ER+乳腺癌的老年女性，手术在肿瘤学上优于 PET。对于身体状况较差、年龄较大的女性，与本研究的匹配队列相似（中位年龄 81 岁，合并症和功能障碍负担更高），BCSS 生存差异至少在 4-5 年随访时消失，这表明对于预期寿命不足 5 年（>90 岁或合并症或虚弱的>85 岁）的患者，可能需要进行个体化决策，决定是否接受 PET 或 S+ET 治疗。Age Gap 在线决策工具（https://agegap.shef.ac.uk/）可以支持这一决策过程。
试验注册
ISRCTN：46099296。
Zotero 插件