Fowble B L, Schultz D J, Overmoyer B, Solin L J, Fox K, Jardines L, Orel S, Glick J H
University of Pennsylvania, School of Medicine, Philadelphia.
Int J Radiat Oncol Biol Phys. 1994 Aug 30;30(1):23-33. doi: 10.1016/0360-3016(94)90515-0.
To assess the impact of young age on outcome in women with early stage breast cancer undergoing conservative surgery and radiation.
Between 1981 and 1991, 980 patients with Stage I and II breast cancer underwent excisional biopsy, axillary dissection, and radiation. The median follow-up was 4.6 years, with a range of 1 month to 11 years. The patients were divided into three groups, based on age at the time of diagnosis: (a) age < or = 35 years--64 patients, (b) age 36-50 years--363 patients, and (c) age > 50 years--553 patients. The comparability of the groups was assessed in terms of clinical factors (tumor size and race), histopathologic factors (histologic subtype, final resection margin, estrogen and progesterone receptor status, pathologic nodal status), and treatment related factors (reexcision, median total dose to the primary, region(s) treated with radiation, and the use of adjuvant systemic chemotherapy and/or tamoxifen). Outcome was evaluated for overall, relapse-free, and cause-specific survival and patterns of first failure (breast, regional nodes, and distant metastasis).
There were no significant differences among the three groups in terms of race, clinical tumor size, pathology of the primary tumor, pathologic nodal status, final margin of resection, progesterone receptor status, median total dose to the primary tumor, or the regions treated. However, younger women were significantly more likely to have estrogen receptor negative tumors, undergo reexcision, and receive adjuvant systemic chemotherapy without tamoxifen. Younger women were found to have a statistically significantly decreased 8-year actuarial relapse-free survival (53% vs. 67% vs. 74%, p = 0.009), cause-specific survival (73% vs. 84% vs. 90%, p = 0.02), freedom from distant metastasis (76% vs. 75% vs. 83%, p = 0.02), and a significantly increased risk of breast recurrence (24% vs. 14% vs. 12%, p = 0.001), and regional node recurrence (7% vs. 1% vs. 1%, p = 0.0002). The patients were further divided on the basis of their pathologic nodal status. There were no statistically significant differences among the three age groups for axillary node-positive patients for overall survival (75% vs. 80% vs. 74%), relapse-free survival (73% vs. 73% vs. 62%), cause-specific survival (76% vs. 85% vs. 80%), and freedom from distant metastasis (75% vs. 75% vs. 72%), or breast recurrence (0% vs. 9% vs. 6%). The findings were identical when the analysis was restricted to node-positive patients who received chemotherapy. However, for axillary node-negative women, young age was associated with a statistically significant decreased overall survival (71% vs. 83% vs. 92%), relapse-free survival (51% vs. 65% vs. 76%), cause-specific survival (71% vs. 86% vs. 93%), freedom from distant metastasis (77% vs. 76% vs. 88%), and a statistically significant increased risk of breast recurrence (40% vs. 16% vs. 13%), and regional node recurrence (3% vs. 1% vs. 0%). The risk of a breast recurrence in axillary node-negative young women was decreased by the addition of adjuvant systemic chemotherapy but not by the use of reexcision.
The present analysis demonstrates that young women with early stage breast cancer do significantly worse when compared to older women in terms of relapse-free survival, cause-specific survival, distant metastasis and breast and regional node recurrence. However, the adverse effect of young age on outcome appears to be limited to the node-negative patients. These findings suggest that node-negative early stage breast cancer in young women is a more aggressive disease, with an increased risk for all patterns of failure and a decreased survival.
评估年轻对接受保乳手术及放疗的早期乳腺癌女性患者预后的影响。
1981年至1991年间，980例I期和II期乳腺癌患者接受了切除活检、腋窝清扫及放疗。中位随访时间为4.6年，范围为1个月至11年。根据诊断时的年龄将患者分为三组：(a)年龄≤35岁——64例患者；(b)年龄36 - 50岁——363例患者；(c)年龄>50岁——553例患者。从临床因素（肿瘤大小和种族）、组织病理学因素（组织学亚型、最终切除边缘、雌激素和孕激素受体状态、病理淋巴结状态）以及治疗相关因素（再次切除、原发灶的中位总剂量、放疗区域、辅助全身化疗和/或他莫昔芬的使用）评估各组的可比性。评估总体生存、无复发生存和特定病因生存情况以及首次失败模式（乳腺、区域淋巴结和远处转移）。
三组在种族、临床肿瘤大小、原发肿瘤病理、病理淋巴结状态、最终切除边缘、孕激素受体状态、原发肿瘤的中位总剂量或放疗区域方面无显著差异。然而，年轻女性更有可能患有雌激素受体阴性肿瘤、接受再次切除且接受无他莫昔芬的辅助全身化疗。发现年轻女性的8年精算无复发生存率在统计学上显著降低（53%对67%对74%，p = 0.009），特定病因生存率（73%对84%对90%，p = 0.02），无远处转移率（76%对75%对83%，p = 0.02），且乳腺复发风险显著增加（24%对14%对12%，p = 0.001）以及区域淋巴结复发风险（7%对1%对1%，p = 0.0002）。根据病理淋巴结状态对患者进一步分组。腋窝淋巴结阳性患者的三组在总生存（75%对80%对74%）、无复发生存（73%对73%对62%）、特定病因生存（76%对85%对80%）、无远处转移（75%对75%对72%）或乳腺复发（0%对9%对6%）方面无统计学显著差异。当分析仅限于接受化疗的淋巴结阳性患者时，结果相同。然而，对于腋窝淋巴结阴性女性，年轻与统计学上显著降低的总生存（71%对83%对92%）、无复发生存（51%对65%对76%）、特定病因生存（71%对86%对93%）、无远处转移（77%对76%对88%）相关，且乳腺复发风险（40%对16%对13%）和区域淋巴结复发风险（3%对1%对0%）在统计学上显著增加。腋窝淋巴结阴性年轻女性的乳腺复发风险通过添加辅助全身化疗而降低，但再次切除未降低该风险。
本分析表明，早期乳腺癌年轻女性与老年女性相比，在无复发生存、特定病因生存、远处转移以及乳腺和区域淋巴结复发方面明显更差。然而，年轻对预后的不利影响似乎仅限于淋巴结阴性患者。这些发现表明，年轻女性的淋巴结阴性早期乳腺癌是一种更具侵袭性的疾病，所有失败模式的风险增加且生存率降低。
