Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer.
Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer.
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近胸辐照的治疗与随后的乳房切除术，并发症以及浸润性乳腺癌的老年妇女的生存之间的关联。
DOI：
10.1001/jama.2012.3481
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发表时间：
2012-05-02
影响因子：
120.7
通讯作者：
Smith, Benjamin D.
中科院分区：
文献类型：
--
作者：
Smith, Grace L.;Xu, Ying;Buchholz, Thomas A.;Giordano, Sharon H.;Jiang, Jing;Shih, Ya-Chen Tina;Smith, Benjamin D.
近距离放射治疗是一种使用植入放射源的放射治疗。近年来，尽管缺乏随机试验数据比较其与标准全乳房照射（WBI）的有效性，但早期乳腺癌肿块切除术后乳房近距离放射治疗的使用已大幅增加。由于长期随机试验的结果将在数年内不会报告，因此需要对非随机设置中的临床结局进行详细分析。在全国范围内接受按服务付费医疗保险的老年乳腺癌女性队列中，比较近距离放射治疗与WBI的乳房保留、并发症和生存率的可能性。一项回顾性人群队列研究，纳入了92735名年龄在67岁或67岁以上的女性，这些女性在2003年至2007年期间被诊断为浸润性乳腺癌，并随访至2008年。肿瘤切除术后，6952例患者接受了近距离放射治疗，85783例患者接受了WBI治疗。使用对数秩检验和比例风险模型比较随后乳房切除术（未能保留乳房的指标）和死亡的累积发生率和校正风险。采用χ2检验和Logistic模型比较术后1年内感染性和非感染性并发症的发生率。使用对数秩检验比较长期并发症的累积发生率。接受近距离放射治疗的女性5年后乳房切除术的发生率（3.95%; 95% CI，3.19%-4.88%）高于WBI（2.18%; 95% CI，2.04%-2.33%; P<0.001），并且在多变量调整后持续存在（风险比[HR]，2.19; 95% CI，1.84-2.61，P<0.001）。近距离放射治疗与更频繁的感染相关，（16.20%; 95% CI，15.34%-17.08% vs 10.33%; 95% CI，10.13%-10.53%; P<0.001;校正比值比[OR]，1.76; 1.64-1.88）和非感染性（16.25%; 95% CI，15.39%-17.14% vs 9.00%; 95% CI，8.81%-9.19%; P<0.001;校正OR，2.03; 95% CI，1.89-2.17）术后并发症; 5年内乳房疼痛的发生率更高（14.55%，95% CI，13.39%-15.80% vs 11.92%; 95% CI，11.63%-12.21%），脂肪坏死（8.26%; 95% CI，7.27-9.38 vs 4.05%; 95% CI，3.87%-4.24%）和肋骨骨折（4.53%; 95% CI，3.63%-5.64% vs 3.62%; 95% CI，3.44%-3.82%; P≤ 0.01）。接受近距离放射治疗的患者的5年总生存率为87.66%（95% CI，85.94%-89.18%），接受WBI治疗的患者为87.04%（95% CI，86.69%-87.39%）（校正HR，0.94; 95% CI，0.84-1.05; P= 0.26）。在一组老年乳腺癌患者中，与WBI相比，近距离放射治疗与更差的长期乳房保留和并发症增加相关，但生存率无差异。
Brachytherapy is a radiation treatment that uses an implanted radioactive source. In recent years, use of breast brachytherapy after lumpectomy for early breast cancer has increased substantially despite a lack of randomized trial data comparing its effectiveness with standard whole-breast irradiation (WBI). Because results of long-term randomized trials will not be reported for years, detailed analysis of clinical outcomes in a nonrandomized setting is warranted. To compare the likelihood of breast preservation, complications, and survival for brachytherapy vs WBI among a nationwide cohort of older women with breast cancer with fee-for-service Medicare. Retrospective population-based cohort study of 92 735 women aged 67 years or older with incident invasive breast cancer, diagnosed between 2003 and 2007 and followed up through 2008. After lumpectomy 6952 patients were treated with brachytherapy vs 85 783 with WBI. Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ2 test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test. Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%–4.88%) vs WBI (2.18%; 95% CI, 2.04%–2.33%; P<.001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84–2.61, P<.001). Brachytherapy was associated with more frequentinfectious (16.20%; 95% CI, 15.34%–17.08% vs 10.33%; 95% CI, 10.13%–10.53%; P<.001; adjusted odds ratio [OR], 1.76; 1.64–1.88) and noninfectious (16.25%; 95% CI, 15.39%–17.14% vs 9.00%; 95% CI, 8.81%–9.19%; P<.001; adjusted OR, 2.03; 95% CI, 1.89–2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%–15.80% vs 11.92%; 95% CI, 11.63%–12.21%), fat necrosis (8.26%; 95% CI, 7.27–9.38 vs 4.05%; 95% CI, 3.87%–4.24%), and rib fracture (4.53%; 95% CI, 3.63%–5.64% vs 3.62%; 95% CI, 3.44%–3.82%; P≤.01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%–89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%–87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84–1.05; P=.26). In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated with worse long-term breast preservation and increased complications but no difference in survival.
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