Individualization of Locoregional Management for Early-Stage Breast Cancer

个体化乳腺癌的局部管理对患者和临床医生都是一个挑战。为乳腺癌管理提供信息而加快引进和采用评价性检查的步伐，可能有助于个体化，但对这些检查的使用模式和影响还没有充分了解。标准治疗包括保乳手术（BCS）全乳放疗与乳房切除术，在成熟的随机试验中，这两种方法的临床效果相当。然而，患者现在也可以接受更积极的方法，包括对侧预防性乳房切除术，或更不积极的方法，如BCS加部分乳房照射（PBI）或在前哨淋巴结活检中对有限转移灶省略腋窝淋巴结清扫（ALND）。如果没有持续的以人群为基础的研究来跟踪和评估如何使用这些检测和治疗来更好地个性化护理，就不能最大限度地发挥快速发展的乳腺癌局部区域管理方法的健康益处。在这种情况下，实现个体化护理的条件是：1)对临床合适的患者进行评估测试；2)接受治疗主要是由循证临床指征驱动的，这些指征涉及无病和总生存期方面的预期益处；3)患者了解情况，对治疗过程感到满意，并将他们的偏好和价值观纳入决策。这里提出的项目是一项以人群为基础的研究，研究对象是新诊断为乳腺癌的患者，并向新泽西州和佐治亚州的SEER登记处及其外科医生报告。目的1是检查诊断为乳腺癌的患者使用较新的评估测试（乳房MRI和BRCA1/2突变基因测试）以及患者和临床医生的相关测试。目的2是检查接受对侧预防性乳房切除术、遗漏ALND和PBI的情况，以及患者和临床医生在接受这些新兴方法进行局部乳腺癌治疗时的相关性。作为这一目标的一部分，我们将评估较新的评估测试对接受治疗的影响。目的3是通过评估患者被告知测试的程度来探索决策的个性化

Individualizing the locoregional management of breast cancer is challenging for both patients and their clinicians. The acceleratetd pace of introduction and adoption of evaluative tests to inform management of breast cancer may facilitate individualization, but the patterns of use and impact of these tests is not sufficiently understood. Standard treatments include breast conserving surgery (BCS) with whole breast radiation vs mastectomy, which have been shown to yield equivalent clinical outcomes in mature randomized trials. However, patients may now also receive more aggressive approaches, including contralateral prophylactic mastectomy, or less aggressive approaches, such as BCS with partial breast irradiation (PBI) or omission of axillary lymph node dissection (ALND) for limited metastases on sentinel node biopsy. The health benefits of the rapidly evolving approaches for breast cancer locoregional management cannot be maximized without ongoing population-based research to track and evaluate how these tests and treatments are used to better individualize care. Individualized care in this context is achieved when 1) evaluative tests are ordered in clinically appropriate patients, 2) treatment receipt is largely driven by evidence-based clinical indications that address expected benefit in terms of disease-free and overall survival, and 3) patients are informed, satisfied with the process, and their preferences and values are incorporated into decisions. The project proposed here is a population-based study of patients newly diagnosed with breast cancer and reported to the SEER registries of New Jersey and Georgia, as well as their surgeons. Aim 1 is to examine the use of newer evaluative tests (breast MRI and genetic testing for BRCA1/2 mutation) for patients diagnosed with breast cancer and the patient and clinician correlates of testing. Aim 2 is to examine the receipt of contralateral prophylactic mastectomy, omission of ALND, and PBI, and the patient and clinician correlates of uptake of these emerging approaches for locoregional management of breast cancer. As part of this aim, we will evaluate the effects of newer evaluative tests on receipt of treatments. Aim 3 is to explore the individualization of decision-making by evaluating the extent to which patients are informed about tests and treatments and are satisfied with the decision-makino process.