Albain K S, Green S R, Lichter A S, Hutchins L F, Wood W C, Henderson I C, Ingle J N, O'Sullivan J, Osborne C K, Martino S
Loyola University Chicago Medical Center, Maywood, IL, USA.
J Clin Oncol. 1996 Nov;14(11):3009-17. doi: 10.1200/JCO.1996.14.11.3009.
To investigate the frequency of breast-sparing treatment among breast cancer patients subsequently enrolled in national cooperative group studies of adjuvant chemotherapy.
A data base was formed of 5,172 patients randomized onto two intergroup trials. Lumpectomy rates were analyzed within study-defined risk strata and across geographic regions. Significant predictors of lower lumpectomy usage were determined in multivariate analyses with variables that described patient and disease characteristics, systemic risk strata, geographic region, and socioeconomic indicators based on zip code of residence.
Breast-conservation rates were 30% in the node-negative and 15% in the node-positive trials, with a wide geographic variation within each study (range, 14% to 49% and 9% to 31%, respectively). Lumpectomy use declined with increasing tumor size and did not exceed 40% even for tumors < or = 1 cm with negative nodes. With increasing risk of systemic relapse, frequency of lumpectomy declined (rates for five strata in order of increasing systemic risk: 41%, 33%, 24%, 18%, and 11%), even though these strata were not known at the time of the surgical decision. A logistic model confirmed the joint significance of geographic region and systemic risk. An exploratory model that adjusted for all important variables identified the following significant predictors of lower lumpectomy use: positive nodes; many positive nodes, increased systemic risk; tumor size > or = 2.0 cm; older age; South, Central or non-New England regions; and either lack of college degree or lower income levels.
Breast-sparing therapy was used in the minority of women subsequently accrued to two national adjuvant breast cancer studies, even though this cohort and their referring surgeons represented a select population. Although multiple concrete factors were independent predictors of lower lumpectomy rates, prospective research is needed into how patients and their physicians approach the mastectomy versus lumpectomy decision.
调查随后参与国家辅助化疗合作组研究的乳腺癌患者中保乳治疗的频率。
建立了一个数据库，纳入了5172例随机分配到两项组间试验的患者。在研究定义的风险分层内以及跨地理区域分析了乳房切除术率。在多变量分析中，通过描述患者和疾病特征、全身风险分层、地理区域以及基于居住邮政编码的社会经济指标的变量，确定了乳房切除术使用率较低的显著预测因素。
在腋窝淋巴结阴性试验中保乳率为30%，腋窝淋巴结阳性试验中为15%，每项研究中地理差异较大（范围分别为14%至49%和9%至31%）。乳房切除术的使用随肿瘤大小增加而下降，即使对于腋窝淋巴结阴性且肿瘤≤1 cm的患者，使用率也未超过40%。随着全身复发风险增加，乳房切除术频率下降（按全身风险增加顺序排列的五个分层的比率分别为：41%、33%、24%、18%和11%），尽管在手术决策时这些分层并不明确。逻辑模型证实了地理区域和全身风险的联合显著性。一个对所有重要变量进行调整的探索性模型确定了以下乳房切除术使用率较低的显著预测因素：腋窝淋巴结阳性；多个腋窝淋巴结阳性、全身风险增加；肿瘤大小≥2.0 cm；年龄较大；南部、中部或非新英格兰地区；以及缺乏大学学历或收入水平较低。
在随后参与两项国家辅助性乳腺癌研究的女性中，少数采用了保乳治疗，尽管该队列及其转诊外科医生代表了特定人群。尽管多个具体因素是乳房切除术率较低的独立预测因素，但仍需要对患者及其医生如何做出乳房切除术与乳房保留手术决策进行前瞻性研究。
