【声音】乳腺癌3种手术方案对比：生存率差异背后还有社会原因！

关键信息

该项研究纳入1998~2011年间189734例乳腺癌患者。双侧乳房切除率从2.0％上升到14.3％，年龄小于40岁的妇女明显增多。与保乳手术和放疗相比，双侧乳房切除术并不能降低死亡率，而单侧乳房切除术与其他手术方案相比死亡率更高。

虽然双侧乳房切除术的使用率有所提高，但与保乳治疗方案相比并没有降低患者死亡率。

专家点评

 

德克萨斯大学医学分校Tricia C Elliott 博士

乳腺癌仍然是美国女性患病和死亡的一个主要原因。一旦确诊，患者与他们的医生常常必须做出艰难的治疗选择，心理和经济影响往往会让患者的决策过程更加艰难。

根据最近Kurian和他的同事们在加州所进行的观察性队列研究，双侧乳房切除术的使用率在过去13年间（1998-2011）一直稳步上升，其中40岁以下的女性的增幅最为明显，从1998年的3.6%增长至2011年的33%，而且大多数是诊断为早期阶段的患者。这项研究回顾了189734名诊断为乳腺癌（阶段0-III）的女性患者，她们有3种手术治疗方案可供选择：单侧乳房切除术，双侧乳房切除术以及保乳手术与放疗相结合（即乳房肿瘤切除合并放疗）。结果显示，与双侧乳房切除术和单侧乳房切除术相比，接受保乳手术合并放疗的患者10年死亡率最低（16.8% vs 18.8%，20.1%），双侧乳房切除术的10年生存率并没有显示出任何优势，而单侧乳房切除术的女性死亡率最高。

双侧乳房切除术是拥有私人保险和能够进入NCI指定的癌症中心的非西班牙裔白人年轻女性最常见的治疗选择，而单侧乳房切除术在50~64岁且依靠医疗补助计划或没有医疗保险的少数名族(菲律宾和西班牙裔) 低收入女性中更为普遍。这类患者群体倾向于选择单侧乳房切除术（意味着更高的10年死亡率）可能受到后期照料问题的影响。保乳手术合并放疗需要执行一段较长时间的每日放射治疗，这就意味着需要每日运送患者到医院，雇人照顾孩子以及脱离工作岗位。这些障碍对于这些患者来说往往难以克服，可能容易造成这一健康差距。

基于该项研究目前尚不清楚为什么双侧乳房切除术没有显示出优于保乳手术合并放疗的疗效。双侧乳房切除术在今年得到媒体更多的报道，一些名人在诊断出BRCA1或BRCA2基因突变后，预防性地选择双侧乳房切除术或进行早期疾病管理。做出双侧乳房切除的决定可能是希望减少或消除癌症复发的机会或发生新的癌变。然而，癌细胞的种植或未察觉的转移仍然可能是双侧乳房切除术术后生存率未能优于保乳手术合并放疗的理论原因。

这项研究提醒医生们需要毫无保留地告知乳腺癌患者所有治疗方案和潜在的结果。在做出治疗决策的过程中，必须考虑到多种因素的影响，这包括一项生物-社会-心理的护理模式。这对于许多病人来说是一个情感创伤时期，对每一种治疗方案的发病率和死亡率有一个更清晰的认识至关重要。此外，这个机会促使我们重新审视医疗体制并进行改革、采取干预措施确保这样的重大医疗不平等和差距能够消除，使所有女性获得最好的照顾和最好的治疗效果。

TAKE-HOME MESSAGE

In this study of 189,734 patients, the rate of bilateral mastectomy increased from 2.0% to 14.3% between 1998 and 2011, with an even greater increase seen among women younger than 40 years old. The use of bilateral mastectomy was not associated with decline in mortality compared with breast-conserving surgery plus radiation, and unilateral mastectomy was associated with higher mortality when compared with the other surgical options.

Although performance of bilateral mastectomy has increased, no associated decrease in mortality has been observed when comparing this option with breast-conserving strategies.

Expert Comment

Breast cancer continues to be a leading cause of morbidity and death in American women. Once diagnosed, women in collaboration with their physician often have to make difficult decisions regarding choice of treatment. The psychosocial and financial impact often weighs on patients’ minds when making such a daunting decision.

According to this recent observational cohort study in California by Kurian and colleagues, incidence of bilateral mastectomies have been steadily rising over the past 13 years (1998–2011), with the greatest increase among women younger than 40 years of age (3.6% in 1998 to 33% in 2011), with the majority diagnosed with early-stage disease. The study reviewed records of 189,734 women diagnosed with breast cancer (stages 0–III) who had one of the three surgical options for treatment: unilateral mastectomy, bilateral mastectomy, or breast-conserving surgery with radiation (ie, lumpectomy with radiation). Women who had breast-conserving surgery with radiation had the lowest 10-year mortality rates (16.8%) compared with those who had bilateral mastectomy (18.8%) and unilateral mastectomy (20.1%). Bilateral mastectomy showed no benefit for survival at 10 years over breast-conserving surgery with radiation, and women who underwent unilateral mastectomy actually had higher mortality rates in comparison with those who underwent the other two types of surgery.

 Bilateral mastectomy was most commonly the choice of younger, non-Hispanic white women with private insurance and access to NCI-designated cancer centers, while unilateral mastectomy was more commonly in women of racial/ethnic minorities (Filipina and Hispanic), between the ages of 50 and 64 years, who had lower incomes, and who tended to have public/Medicaid insurance or no insurance. This higher incidence of unilateral mastectomy (which was also associated with a higher 10-year mortality rate) in this group of women may be influenced by issues of access to care. Breast-conserving surgery with radiation requires a commitment to daily radiation treatment over an extended period of time, which requires transportation to the doctor/facility, finding care for children, and time away from work. These barriers are often difficult to surmount and may readily contribute to this demonstrated health disparity.

It is not clear from the study why bilateral mastectomy showed no benefit over breast-conserving surgery with radiation. Bilateral mastectomies have been receiving more press coverage in the recent years, with celebrities choosing this option prophylactically after diagnosis of BRCA1 or BRCA2 mutations or for management of their early-stage disease. The decision of a bilateral mastectomy is likely based on the hope to decrease or eliminate the chance for recurrence or developing a new cancer in the other breast. However, seeding of cancer cells or undetectable metastasis is still a possibility and may be a theoretical reason for the observation of no survival benefit in comparison with breast-conserving surgery with radiation.

This study highlights the need for physicians to thoroughly counsel patients on all of the therapeutic options for the treatment of breast cancer and the potential results. Multiple factors must be considered to facilitate a shared-decision process, which incorporates a bio–psychosocial–spiritual model of care. This is an emotionally traumatic time for many patients, and having a clearer understanding of the morbidity and mortality associated with each of the treatment options is critical. Additionally, this is an opportunity to look within our healthcare system for reform and interventions to ensure that such significant healthcare inequities and disparities are eliminated and that all women have access to the best care and the best possible outcome.

 JAMA : The Journal of the American Medical Association

Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011

JAMA 2014 Sep 03;312(9)902-914, AW Kurian, DY Lichtensztajn, TH Keegan, DO Nelson, CA Clarke, SL Gomez

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

This abstract is available on the publisher's site.

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