Individualization of Locoregional Management for Early-Stage Breast Cancer

乳腺癌局部区域管理的个体化对患者和他们的临床医生来说都是具有挑战性的。为乳腺癌治疗提供信息的评估测试的引入和采用的步伐加快，可能有助于个体化，但这些测试的使用模式和影响还没有得到充分的了解。标准治疗包括全乳房放射保乳手术(BCS)和乳房切除术，后者在成熟的随机试验中已被证明产生了相同的临床结果。然而，患者现在也可能接受更积极的方法，包括对侧预防性乳房切除术，或不那么积极的方法，如BCS联合部分乳房照射(PBI)或因前哨淋巴结活检的有限转移而省略腋窝淋巴结清扫(ALND)。如果没有正在进行的基于人群的研究来跟踪和评估如何使用这些测试和治疗来更好地个性化护理，快速发展的乳腺癌局部区域管理方法的健康益处是无法最大化的。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)接受治疗在很大程度上是由循证临床适应症推动的，这些指征解决了无病和总存活率方面的预期好处；3)患者对治疗过程知情、满意，并将他们的喜好和价值观纳入决策。这里提出的项目是一项基于人群的研究，对新诊断为乳腺癌的患者进行研究，并向新泽西州和佐治亚州的SEER登记处以及他们的外科医生报告。目的1是检查新的评估测试(乳腺MRI和BRCA1/2突变的基因测试)在诊断为乳腺癌的患者中的使用情况以及患者和临床医生测试的相关性。目的2是检查对侧预防性乳房切除术的接受情况，忽略ALND和PBI，以及患者和临床医生接受这些新的乳腺癌局部区域管理方法的相关性。作为这一目标的一部分，我们将评估接受治疗的较新评估测试的效果。目标3是通过评估患者被告知测试的程度来探索决策的个人化 并对决策过程感到满意。

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-making process.