The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis
The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis
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DOI：
10.1093/annonc/mdw046
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发表时间：
2016-05-01
影响因子：
50.5
通讯作者：
Fisher, C. M.
中科院分区：
文献类型：
--
作者：
Rusthoven, C. G.;Rabinovitch, R. A.;Fisher, C. M.
目前尚无随机数据来描述乳腺癌新辅助化疗后乳房切除术后放疗 (PMRT) 和区域淋巴结放疗 (RNI) 对总生存 (OS) 的影响。在 NCDB 的一项针对 15000 多名 cN1 女性的研究中，PMRT 与所有病理性淋巴结亚组（ypN0、ypN1、ypN2-3）的 OS 改善相关； RNI 未观察到 OS 差异。新辅助化疗 (NAC) 后，保乳手术 (BCS) 后乳房切除术后放疗 (PMRT) 和区域淋巴结照射 (RNI) 的最佳策略存在争议。在这项分析中，我们评估了这些放射治疗 (RT) 方法对国家癌症数据库 (NCDB) 中接受 NAC 治疗的临床淋巴结阳性乳腺癌女性的影响。接受 NAC 治疗的 cT1-3 cN1 M0 乳腺癌女性根据手术 [乳房切除术 (Mast) 与 BCS] 和化疗后病理淋巴结状态（ypN0 与 ypN+）分为四个队列。使用 Kaplan-Meier 方法估计总生存期 (OS)，并使用对数秩检验、多变量 Cox 模型和倾向评分匹配分析对 RT 方法进行分析。从 2003 年到 2011 年，确定了 15 315 例病例，其中包括 3040 例 Mast-ypN0、7243 例 Mast-ypN+、2070 例 BCS-ypN0 和 2962 例BCS-ypN+ 患者。在单变量分析中，PMRT 与 Mast-ypN0 (P = 0.019) 和 Mast-ypN+ (P < 0.001) 患者的 OS 改善相关。在调整了年龄、合并症评分、cT 分期、乳腺病理完全缓解、腋窝手术、ypN 分期、雌激素受体状态和激素治疗等因素的多变量分析中，PMRT 仍然与 Mast-ypN0 患者的 OS 改善独立相关[风险比 (HR) = 0.729，95% 置信区间 (CI) 0.566-0.939，P = 0.015] 和Mast-ypN+ 患者（HR = 0.772，95% CI 0.689-0.866，P < 0.001）。对于 BCS-ypN0 或 BCS-ypN+ 患者，在乳房放疗中添加 RNI 后，未观察到 OS 存在差异。倾向评分匹配分析表明了相同的显着性模式。在子集分析中，PMRT 在每个病理淋巴结亚组（ypN0、ypN1 和 ypN2-3）中的 OS 均得到改善（所有 P < 0.05）。在针对接受 NAC 治疗的 cN1 患者的最大报告 RT 分析中，PMRT 与所有病理淋巴结亚组的 OS 改善相关。在乳房 RT 中添加 RNI 后，未观察到 OS 差异。
No randomized data are currently available to characterize the overall survival (OS) impact of postmastectomy radiation (PMRT) and regional nodal irradiation (RNI) after neoadjuvant chemotherapy for breast cancer. In a study of over 15000 cN1 women in the NCDB, PMRT was associated with improved OS for all pathologic nodal subgroups (ypN0, ypN1, ypN2-3); no OS differences were observed with RNI.Following neoadjuvant chemotherapy (NAC), the optimal strategies for postmastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after breast-conserving surgery (BCS) are controversial. In this analysis, we evaluate the impact of these radiotherapy (RT) approaches for women with clinically node-positive breast cancer treated with NAC in the National Cancer Database (NCDB).Women with cT1-3 cN1 M0 breast cancer treated with NAC were divided into four cohorts by surgery [Mastectomy (Mast) versus BCS] and post-chemotherapy pathologic nodal status (ypN0 versus ypN+). Overall survival (OS) was estimated using the Kaplan-Meier method and RT approaches were analyzed using the log-rank test, multivariate Cox models, and propensity score-matched analyses.From 2003 to 2011, 15 315 cases were identified including 3040 Mast-ypN0, 7243 Mast-ypN+, 2070 BCS-ypN0, and 2962 BCS-ypN+ patients. On univariate analysis, PMRT was associated with improved OS for both Mast-ypN0 (P = 0.019) and Mast-ypN+ (P < 0.001) patients. On multivariate analyses adjusted for factors including age, comorbidity score, cT stage, in-breast pathologic complete response, axillary surgery, ypN stage, estrogen receptor status and hormone therapy, PMRT remained independently associated with improved OS among Mast-ypN0 [hazard ratio (HR) = 0.729, 95% confidence interval (CI) 0.566-0.939, P = 0.015] and Mast-ypN+ patients (HR = 0.772, 95% CI 0.689-0.866, P < 0.001). No differences in OS were observed with the addition of RNI to breast RT for BCS-ypN0 or BCS-ypN+ patients. Propensity score-matched analyses demonstrated identical patterns of significance. On subset analysis, OS was improved with PMRT in each pathologic nodal subgroup (ypN0, ypN1, and ypN2-3) (all P < 0.05).In the largest reported analysis of RT for cN1 patients treated with NAC, PMRT was associated with improved OS for all pathologic nodal subgroups. No OS differences were observed with the addition of RNI to breast RT.