JAMA oncology|外科医生对早期乳腺癌腋窝切除的态度

           

JAMA oncology|外科医生对早期乳腺癌腋窝切除的态度



美国外科医师肿瘤小组(ACOSOG) Z0011研究表明,对接受保乳治疗的临床淋巴结检查阴性、存在1-2个前哨淋巴结转移的妇女进行前哨淋巴结活检,是具有安全性的。而外科医生对于什么时候可以无需腋窝淋巴结清扫(ALND)所持的观点,目前尚不明确

最新发现

  为了确定外科医生对ACOSOG Z0011研究结果的接受程度,确定与接受ACOSOG Z0011结果相关的特征,并检查外科肿瘤学会和美国放射肿瘤学学会接受肿瘤零墨迹阴性边缘与外科医生对ALND的偏好之间的关系。


  研究人员向488名外科医生发送了一份调查问卷,调查对象是基于人群的女性早期乳腺癌患者样本(N = 5080)。研究时间为2013年7月1日至2015年8月31日。根据ALND量表的外四分位数分布,将外科医生分为低、中、高ALND倾向者。采用多元线性回归模型来确定独立关联。


  在488名被邀请参与的外科医生中,376名(77.0%)作出了回应,359名医生提供了关于5种临床情景的ALND倾向的完整信息。这些外科医生平均年龄为53.7岁(范围31-80岁);277(73.7%)为男性;142人(37.8%)每年治疗20例或更少乳腺癌,108人(28.7%)治疗50例以上。175人(49.0%)推荐ALND用于大转移情况。在不太倾向于推荐ALND的外科医生中,只有1名(1.1%)支持ALND用于任何淋巴结转移的情况,而认为该选择性应用和倾向于支持应用的外科医生分别为69名(38.6%)和85名(95.5%)(P < .001)。

  在多变量分析中,外科医生的观点与背景也与其患者的后续情况有相关性:较低的ALND倾向与较高的乳腺癌发病率显著相关(21-50: - 0.19;95% CI,- 0.39 - 0.02;> 51:−0.48;95% CI,- 0.71 - 0.24;P < .001),建议最小边缘宽度(1-5毫米:- 0.10;95% CI,- 0.43 - 0.22;肿瘤无墨迹:- 0.53;95% CI,- 0.82 - 0.24;P < .001),参与多学科肿瘤委员会(1%-9%:- 0.25;95% CI, - 0.55 - 0.05;> 9%:−0.37;95% CI,- 0.63 - 0.11;和洛杉矶监测、流行病学和最终结果站点(- 0.18;95% CI,- 0.35 - 0.01;P = .04)。

这项研究显示,外科医生对较局限性的乳腺癌手术的接受程度存在显著差异,这与乳腺癌体积较大以及多学科互动有关,表明许多患者可能会出现过度治疗,需要针对体积更小的乳腺手术制定教学研究方案。目前,根据临床淋巴结状况、包含转移的SNs数目、肿瘤切除或乳房切除的选择以及是否给予新辅助治疗,以及对腋窝进行的治疗是不同的。制定一个循证实用指南,概述这些患者亚组中可接受的ALND替代方案,是目前需要优先考虑的问题。

摘要原文

Importance  

The American College of Surgeons Oncology Group (ACOSOG) Z0011 study demonstrated the safety of sentinel node biopsy alone in clinically node-negative women with metastases in 1 or 2 sentinel nodes treated with breast conservation. Little is known about surgeon perspectives regarding when axillary lymph node dissection (ALND) can be omitted.


Objectives 

To determine surgeon acceptance of ACOSOG Z0011 findings, identify characteristics associated with acceptance of ACOSOG Z0011 results, and examine the association between acceptance of the Society of Surgical Oncology and American Society for Radiation Oncology negative margin of no ink on tumor and surgeon preference for ALND.


Design, Setting, and Participants  

A survey was sent to 488 surgeons treating a population-based sample of women with early-stage breast cancer (N = 5080). The study was conducted from July 1, 2013, to August 31, 2015.


Main Outcomes and Measures  

Surgeons were categorized as having low, intermediate, or high propensity for ALND according to the outer quartiles of ALND scale distribution. A multivariable linear regression model was used to confirm independent associations.


Results  

Of the 488 surgeons invited to participate, 376 (77.0%) responded and 359 provided complete information regarding propensity for ALND derived from 5 clinical scenarios. Mean surgeon age was 53.7 (range, 31-80) years; 277 (73.7%) were male; 142 (37.8%) treated 20 or fewer breast cancers annually and 108 (28.7%) treated more than 50. One hundred seventy-five (49.0%) recommended ALND for 1 macrometastasis. Of low-propensity surgeons who recommended ALND, only 1 (1.1%) approved ALND for any nodal metastases compared with 69 (38.6%) and 85 (95.5%) of selective and high-propensity surgeons (P < .001), respectively. In multivariable analysis, lower ALND propensity was significantly associated with higher breast cancer volume (21-50: −0.19; 95% CI, −0.39 to 0.02; >51: −0.48; 95% CI, −0.71 to −0.24; P < .001), recommendation of a minimal margin width (1-5 mm: −0.10; 95% CI, −0.43 to 0.22; no ink on tumor: −0.53; 95% CI, −0.82 to −0.24; P < .001), participation in a multidisciplinary tumor board (1%-9%: −0.25; 95% CI, −0.55 to 0.05; >9%: −0.37; 95% CI, −0.63 to −0.11; P = .02), and Los Angeles Surveillance, Epidemiology, and End Results site (−0.18; 95% CI, −0.35 to −0.01; P = .04).


Conclusions and Relevance  

This study shows substantial variation in surgeon acceptance of more limited surgery for breast cancer, which is associated with higher breast cancer volume and multidisciplinary interactions, suggesting the potential for overtreatment of many patients and the need for education targeting lower-volume breast surgeons.


参考文献

MORROW M, JAGSI R, MCLEOD M C, et al. Surgeon Attitudes Toward the Omission of Axillary Dissection in Early Breast Cancer[J]. JAMA Oncology, 2018,4(11):1511.





Powered by 上海翼石信息科技有限公司 © 2001-2016 dayibian Inc.
沪ICP备12046386号-1