Determinants of Breast Conservation Rates: Reasons for Mastectomy at a Comprehensive Cancer Center
Determinants of Breast Conservation Rates: Reasons for Mastectomy at a Comprehensive Cancer Center
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DOI：
10.1111/j.1524-4741.2008.00668.x
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发表时间：
2009-01-01
期刊：
影响因子：
2.1
通讯作者：
Sabel, Michael S.
中科院分区：
文献类型：
--
作者：
Lee, M. Catherine;Rogers, Kendra;Sabel, Michael S.
转诊模式的偏差和多学科管理的变化可能会影响医院之间的乳房保护治疗（BCT）率。BCT率的回顾性研究由于无法区分乳房切除术与患者选择的乳房切除术而受到限制。我们的前瞻性乳腺癌数据库查询了在密歇根大学接受手术治疗超过3年的浸润性乳腺癌患者。沿着记录人口统计学、分期和组织学以及进行乳房切除术的原因，分类为“根据需要”（BCT的禁忌症）或“根据选择”。“多变量分析用于确定与选择乳房切除术显著相关的因素。BCT与肿瘤大小、组织学和淋巴结状态相关，但与年龄无关，无论是选择还是需要。34%的患者最初认为BCT的候选人不佳，44%的患者绝对禁忌BCT，而56%的患者认为肿瘤与乳房的大小比例过大，无法成功进行BCT。在后一组中，80%的患者接受了新辅助化疗，试图降低原发肿瘤的分期并进行BCT，这在一半以上的患者中是成功的。对于最初被认为是BCT良好候选者的患者，只有15%选择接受乳房切除术，而5%最终由于未能实现阴性边缘而需要乳房切除术。总体而言，BCT率为63%，但如果不使用新辅助化疗，BCT率仅为53%。在三级转诊中心，BCT率更多地由禁忌症而不是患者选择驱动，并且由于转诊模式，可能严重偏向乳房切除术。除了肿瘤分期和组织学等因素外，新辅助化疗或遗传咨询也会显著影响BCT率。因此，仅将BCT率作为质量的衡量标准，并不是服务于不同人群的机构的适当标准。
Bias in referral patterns and variations in multi-disciplinary management may impact breast conservation therapy (BCT) rates between hospitals. Retrospective studies of BCT rates are limited by their inability to differentiate indicated mastectomies versus those chosen by the patient. Our prospective breast cancer data base was queried for patients with invasive breast cancer who underwent surgical therapy at the University of Michigan over a 3-year period. Demographics, stage and histology were recorded along with the reason mastectomy was performed, categorized as "by need" (contraindication to BCT) or "by choice." Multivariate analysis was used to identify factors significantly associated with mastectomy by choice. BCT was associated with tumor size, histology and nodal status, but not older age, either by choice or by need. Of the 34% of patients initially felt to be poor candidates for BCT, it was absolutely contraindicated in 44%, while 56% were thought to have a tumor-to-breast size ratio too large for successful BCT. Of this latter group, 80% underwent neo-adjuvant chemotherapy in an attempt to downstage the primary tumor and perform BCT, which was successful in over half the patients. For the patients initially thought to be good candidates for BCT, only 15% chose to undergo mastectomy, while 5% eventually required mastectomy due to failed attempts to achieve negative margins. Overall, the BCT rate was 63%, however without the use of neo-adjuvant chemotherapy, the BCT rate would have been only 53%. At a tertiary referral center, BCT rates are driven more by contraindications than patient choice, and may be heavily skewed towards mastectomy due to referral patterns. In addition to tumor factors such as stage and histology, BCT rate can be dramatically impacted by neo-adjuvant chemotherapy or genetic counseling. Examining BCT rates alone as a measure of quality, therefore, is not an appropriate standard across institutions serving diverse populations.