Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis.
Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis.
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DOI：
10.1001/jama.2010.1720
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发表时间：
2010-12-01
影响因子：
120.7
通讯作者：
McMahon, Pamela M.
中科院分区：
文献类型：
--
作者：
Hayes, Julia H.;Ollendorf, Daniel A.;Pearson, Steven D.;Barry, Michael J.;Kantoff, Philip W.;Stewart, Susan T.;Bhatnagar, Vibha;Sweeney, Christopher J.;Stahl, James E.;McMahon, Pamela M.
在美国，2009年有192000名男性被诊断患有前列腺癌，其中大多数是低风险的临床局部疾病。这些癌症的治疗与相当高的发病率有关。积极监测是初始治疗的替代方案，但长期结果和对生活质量的影响尚未得到很好的表征。研究低风险、临床局限性前列腺癌患者主动监测与初始治疗相比的生活质量获益和风险。使用模拟模型进行决策分析：男性在诊断时接受近距离放射治疗、调强放射治疗（IMRT）或根治性直肠切除术治疗，或通过主动监测进行随访（一种通过连续前列腺特异性抗原测量、直肠指检和活检密切监测新诊断患者的策略，并在疾病进展或患者选择时进行治疗）。概率和效用来自以前的研究和文献综述。在基础病例中，初始治疗与主动监测的前列腺癌特异性死亡的相对风险假定为0.83。男性遭受了短期和长期的治疗不良反应。新诊断为临床局限性低风险前列腺癌（前列腺特异性抗原水平<10 ng/mL，分期≤ T2 a疾病，Gleason评分≤6）的65岁男性的假设队列。质量调整预期寿命（QALE）。主动监测与最大的QALE（11.07质量调整生命年[Qs]）相关，其次是近距离放射治疗（10.57 Qs），IMRT（10.51 Qs）和根治性直肠癌切除术（10.23 Qs）。主动监测仍然与最高的QALE相关，即使初始治疗与主动监测的前列腺癌特异性死亡的相对风险低至0.6。然而，QALE收益和最佳策略高度依赖于个人的喜好生活在积极的监督和治疗。在广泛的假设下，对于一名65岁的男性，与初始治疗相比，基于QALE，积极监测是一种合理的低风险前列腺癌治疗方法。然而，个人偏好在决定是否治疗或进行主动监测方面发挥着核心作用。
In the United States, 192 000 men were diagnosed as having prostate cancer in 2009, the majority with low-risk, clinically localized disease. Treatment of these cancers is associated with substantial morbidity. Active surveillance is an alternative to initial treatment, but long-term outcomes and effect on quality of life have not been well characterized. To examine the quality-of-life benefits and risks of active surveillance compared with initial treatment for men with low-risk, clinically localized prostate cancer. Decision analysis using a simulation model was performed: men were treated at diagnosis with brachytherapy, intensity-modulated radiation therapy (IMRT), or radical prostatectomy or followed up by active surveillance (a strategy of close monitoring of newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations, and biopsies, with treatment at disease progression or patient choice). Probabilities and utilities were derived from previous studies and literature review. In the base case, the relative risk of prostate cancer–specific death for initial treatment vs active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment. Hypothetical cohorts of 65-year-old men newly diagnosed as having clinically localized, low-risk prostate cancer (prostate-specific antigen level <10 ng/mL, stage ≤T2a disease, and Gleason score ≤6). Quality-adjusted life expectancy (QALE). Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs). Active surveillance remained associated with the highest QALE even if the relative risk of prostate cancer–specific death for initial treatment vs active surveillance was as low as 0.6. However, the QALE gains and the optimal strategy were highly dependent on individual preferences for living under active surveillance and for having been treated. Under a wide range of assumptions, for a 65-year-old man, active surveillance is a reasonable approach to low-risk prostate cancer based on QALE compared with initial treatment. However, individual preferences play a central role in the decision whether to treat or to pursue active surveillance.
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