Hillner B E, Desch C E, Carlson R W, Smith T J, Esserman L, Bear H D
Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0170, USA.
J Clin Oncol. 1996 Jan;14(1):70-7. doi: 10.1200/JCO.1996.14.1.70.
To assess the trade-offs between survival and breast preservation of currently accepted approaches for ductal carcinoma-in-situ (DCIS) of the breast.
Decision analysis was performed using the Markov model of hypothetical cohorts of 55-year-old white women with nonpalpable mammographic abnormalities found to be DCIS. Strategies were breast-conserving surgery (BCS), BCS with 50-Gy radiation (RT) or initial mastectomy. Recurrence rates were derived from the published literature. Main outcomes were overall, breast cancer-free, and event-free survival plus years of both breasts preserved.
Using the conditions defined in this model, the actuarial survival rates at 10 and 20 years were 91.7% and 74.1% for the initial mastectomy strategy, 91.0% and 72.1% for BCS plus RT, and 89.6% and 68.2% for BCS alone. At 20 years, the initial mastectomy strategy also had a greater breast cancer-free survival rate of 74.5%, compared with 63.3% for BCS plus RT, or 46.8% for BCS alone. However, BCS alone had the highest survival rate with both breasts preserved (64.2%) compared with BCS plus RT (56.0%) or initial mastectomy (0%). Of the breast-conserving strategies at 20 years, the breast event-free survival rate (no invasive cancer or DCIS) was greater for BCS plus RT (47.2%) compared with BCS alone (28.4%). Using just survival as the primary end point, mastectomy is the optimal strategy by a small margin. However, if quality-adjusted survival is at issue, mastectomy is the choice only if the yearly reduction in quality of life due to mastectomy is less than 1%.
BCS with or without radiation compared with mastectomy as initial management of DCIS of the breast trades a slight decrease in survival rates for the value of breast preservation. This model should aid clinicians in matching treatments to their patients' preferences.
评估目前公认的乳腺导管原位癌（DCIS）治疗方法在生存和保乳之间的权衡。
采用马尔可夫模型对55岁的白人女性进行决策分析，这些女性乳房X线摄影检查发现有不可触及的异常，经诊断为DCIS。策略包括保乳手术（BCS）、50 Gy放疗（RT）联合BCS或初始乳房切除术。复发率来自已发表的文献。主要结局包括总生存率、无乳腺癌生存率、无事件生存率以及双侧乳房保留的年数。
根据该模型定义的条件，初始乳房切除术策略在10年和20年的精算生存率分别为91.7%和74.1%，BCS联合RT分别为91.0%和72.1%，单纯BCS分别为89.6%和68.2%。在20年时，初始乳房切除术策略的无乳腺癌生存率也更高，为74.5%，而BCS联合RT为63.3%，单纯BCS为46.8%。然而，单纯BCS保留双侧乳房的生存率最高（64.2%），相比之下，BCS联合RT为56.0%，初始乳房切除术为0%。在20年的保乳策略中，BCS联合RT的无乳房事件生存率（无浸润性癌或DCIS）高于单纯BCS（47.2% vs 28.4%）。仅将生存作为主要终点时，乳房切除术是略优的策略。然而，如果涉及质量调整后的生存，只有当乳房切除术导致的生活质量每年下降幅度小于1%时，乳房切除术才是选择。
与乳房切除术相比，BCS联合或不联合放疗作为DCIS的初始治疗方法，在生存率上略有下降，但换取了保乳的价值。该模型应有助于临床医生根据患者的偏好匹配治疗方案。
