Recent Trends in Chemotherapy Use and Oncologists' Treatment Recommendations for Early-Stage Breast Cancer
Recent Trends in Chemotherapy Use and Oncologists' Treatment Recommendations for Early-Stage Breast Cancer
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DOI：
10.1093/jnci/djx239
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发表时间：
2018-05-01
影响因子：
10.3
通讯作者：
Katz, Steven J.
中科院分区：
文献类型：
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作者：
Kurian, Allison W.;Bondarenko, Irina;Katz, Steven J.
背景：随着时间的推移，乳腺癌的治疗效果有所改善，人们对过度治疗的担忧日益增加。然而，鲜为人知的是如何化疗的使用和肿瘤学家的建议已经改变了在最近几年。方法：我们调查了5080名妇女（70%的响应率）诊断为乳腺癌在2013年和2015年之间，并通过两个监测，流行病学和最终结果登记（格鲁吉亚和洛杉矶）关于化疗的收据和肿瘤学家的化疗建议。我们调查了504名主治肿瘤学家（60.3%的应答率）关于淋巴结阴性和淋巴结阳性病例的化疗建议。我们对化疗使用情况和患者对肿瘤学家建议的报告进行了描述性统计，并根据时间和临床因素使用了化疗使用的广义线性混合模型。结果：分析样本为2926例I-II期雌激素受体阳性、人表皮生长因子受体2阴性乳腺癌患者。从2013年到2015年，保持其他因素不变，估计化疗使用率从34.5%（95%置信区间[CI] = 30.8%至38.3%）下降到21.3%（95% CI = 19.0%至23.7%，P <0.001）。估计化疗使用率从26.6%下降到26.6%，（95% CI = 23.0%至30.7%）至14.1%（95% CI = 12.0%至16.3%），淋巴结阴性/微转移患者和81.1%对于淋巴结阳性患者，95% CI = 76.6%至85.0%）至64.2%（95% CI = 58.6%至69.6%）。在淋巴结阴性/微转移患者中，21个基因复发评分（RS）的使用没有变化，而淋巴结阳性患者中RS使用的增加占化疗下降的三分之一。在控制其他因素后，患者报告肿瘤医生建议化疗的比例从44.9%（95%CI = 40.2%~ 49.7%）下降到31.6%（95%CI = 25.9%~ 37.9%）。如果患者的偏好与他们的建议不一致，肿瘤学家更有可能订购RS（67.4%，95% CI = 61.7%至73.0%，与17.5%，95% CI = 13.1%至22.0%，一致），他们根据患者的偏好和RS结果调整建议。
Background: There is growing concern about overtreatment of breast cancer as outcomes have improved over time. However, little is known about how chemotherapy use and oncologists' recommendations have changed in recent years.Methods: We surveyed 5080 women (70% response rate) diagnosed with breast cancer between 2013 and 2015 and accrued through two Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles) about chemotherapy receipt and their oncologists' chemotherapy recommendations. We surveyed 504 attending oncologists (60.3% response rate) about chemotherapy recommendations in node-negative and node-positive case scenarios. We conducted descriptive statistics of chemotherapy use and patients' report of oncologists' recommendations and used a generalized linear mixed model of chemotherapy use according to time and clinical factors. All statistical tests were two-sided.Results: The analytic sample was 2926 patients with stage I-II, estrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. From 2013 to 2015, keeping other factors constant, chemotherapy use was estimated to decline from 34.5% (95% confidence interval [CI] = 30.8% to 38.3%) to 21.3% (95% CI = 19.0% to 23.7%, P < .001). Estimated decline in chemotherapy use was from 26.6% (95% CI = 23.0% to 30.7%) to 14.1% (95% CI = 12.0% to 16.3%) for node-negative/ micrometastasis patients and from 81.1% (95% CI = 76.6% to 85.0%) to 64.2% (95% CI = 58.6% to 69.6%) for node-positive patients. Use of the 21-gene recurrence score (RS) did not change among node-negative/micrometastasis patients, and increasing RS use in node-positive patients accounted for one-third of the chemotherapy decline. Patients' report of oncologists' recommendations for chemotherapy declined from 44.9% (95% CI = 40.2% to 49.7%) to 31.6% (95% CI = 25.9% to 37.9%), controlling for other factors. Oncologists were much more likely to order RS if patient preferences were discordant with their recommendations (67.4%, 95% CI = 61.7% to 73.0%, vs 17.5%, 95% CI = 13.1% to 22.0%, concordant), and they adjusted recommendations based on patient preferences and RS results.