JAMA：乳腺癌短距离放疗的优势和劣势比较

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JAMA：乳腺癌短距离放疗的优势和劣势比较
2012-05-03
乳腺癌放射治疗领域的一位牛掰专家指出，发表在JAMA杂志上的一篇关于乳腺癌治疗的新研究里面有一些错误信息，可能会带来阻止女性接受近乳房距离放射疗法——一种安全有效的治疗方法这一不必要的后果。Robert Kuske博士是乳房近距离放射疗法领域的一位先驱者，也是两项主要的临床试验的共同主要研究者，他对发表在JAMA杂志上的这篇文章提出了质疑。安德森癌症中心的研究者们共同完成的这篇文章将在5月2日发表，它报告了与全乳房放射（WBI）相比，乳房近距离放射（也被称为部分乳房加速照射，或APBI）的并发症略有增加。

Kuske博士是一个为一些特定病人的利益直言不讳的乳房近距离放射方面的研究者，他指出JAMA上发表的这篇文章里，将WBI结果与一些年龄更大的、放射剂量控制较差的接受乳房近距离放射疗法的患者进行比较。更新的研究显示，“单通道”气球疗法正在被“基于strut”的乳房近距离放射疗法所取代，而后者可以让肿瘤科医生在剂量云成型上有更大的空间。

如果不受到质疑，发表在JAMA上的这篇文章是否会阻止女性接受现代化的乳房近距离放射疗法呢？Kuske博士担心这恐怕恰恰会发生，并会危及他共同领导的一项长期的、非常重要的试验"NSABP B-39"。

Kuske博士说，在JAMA上的这篇文章里：
•不是一项临床研究，且不能得出肿瘤复发率；
•没有发现WBI与乳房近距离放射疗法二者在总体生存率上存在差异；
•利用的是老式的乳房近距离放射疗法的资料，而其较高的皮肤接触剂量可解释其带来的副作用及并发症的不同；
•显示仅仅只有1.77%的乳房切除率差异；
•是一项利用Medicare SEER数据库进行的回顾性综述，这里面可能存在一些因素，如准确性较差、资料不完整、选择性偏倚等。对此数据库资料进行的研究在科学领域里面是出了名的不可靠；
•研究方法有瑕疵。对于乳房切除资料方面，并不清楚到底是哪一侧乳房被切除，切除原因也不清楚。

在新治疗方法的优点里（从JAMA上这篇文章提供的资料中总结得到），新的乳房近距离放射疗法可以：
•获得更好的美学效果，副作用更少；
•准确的将剂量释放至需要的位置，降低健康组织的放射暴露；
•极大的降低了治疗相关的疲劳；
•通过提供更高靶向的治疗和显著缩短治疗时间而能更好的适应忙碌女性的需求；
•如果癌症复发，可有更多的治疗选择。

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相关文献
Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer.
JAMA 2012 May;30717:1827-37

Smith GL Xu Y Buchholz TA Giordano SH Jiang J Shih YC Smith BD

Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA. bsmith3@mdanderson.org

Abstract
Brachytherapy is a radiation treatment that uses an implanted radioactive source. In recent years, use of breast brachytherapy after lumpectomy for early breast cancer has increased substantially despite a lack of randomized trial data comparing its effectiveness with standard whole-breast irradiation (WBI). Because results of long-term randomized trials will not be reported for years, detailed analysis of clinical outcomes in a nonrandomized setting is warranted. To compare the likelihood of breast preservation, complications, and survival for brachytherapy vs WBI among a nationwide cohort of older women with breast cancer with fee-for-service Medicare. Retrospective population-based cohort study of 92,735 women aged 67 years or older with incident invasive breast cancer, diagnosed between 2003 and 2007 and followed up through 2008. After lumpectomy 6952 patients were treated with brachytherapy vs 85,783 with WBI. Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ(2) test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test. Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P < .001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84-2.61, P < .001). Brachytherapy was associated with more frequent infectious (16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P < .001; adjusted odds ratio [OR], 1.76; 1.64-1.88) and noninfectious (16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P < .001; adjusted OR, 2.03; 95% CI, 1.89-2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%), fat necrosis (8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%), and rib fracture (4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; P ≤ .01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%-89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%-87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84-1.05; P = .26). In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated worse with long-term breast preservation and increased complications but no difference in survival.

掉颗牙

通读两遍，看明白了。谢谢你，总是给大家带来最新的乳腺癌资讯，作为一个此病的患者，在你的文章里总是看到希望。

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JAMA：乳腺癌近距离放疗应慎重使用
2012-05-05
近距离放射疗法是一种利用植入性放射源来进行放疗的手段。近些年中，在对早期乳腺癌进行肿瘤切除术后施行乳腺近距离放疗的案例已经有了大幅的增加，然而，将其与标准化全乳房照射（WBI）进行功效比较的随机化的试验数据仍然缺乏。

美国德克萨斯大学MD Anderson癌症中心的Grace L. Smith, M.D., Ph.D., M.P.H.及其同事们开展了一项研究，旨在比较被诊断患有浸润性乳腺癌的医疗保险受益的老年病人中乳腺近距离放疗 VS WBI对乳房长期保全的可能性、并发症及存活率的影响。相关成果发表在JAMA最新一期在线版。

这一基于人口的回顾性研究共纳入了9,2735名年龄在67岁或以上的罹患浸润性乳腺癌的妇女，她们是在2003至2007年间被诊断并一直随访至2008年。在肿块切除后，6952名患者接受了近距离放疗，另有 8,5783名患者接受了WBI。主要研究指标为后续手术（保乳失败）的累积发生率，校正后的危险比及死亡率，均通过时序检测和比例风险回归模型得到。此外，研究者还利用χ2检验和逻辑模型比较两组间1年内患者术后感染和非感染性并发症的比例，长期并发症的积累发生率则依靠时序检验得到。

研究人员发现，乳腺近距离放疗与随后的乳房切除术的较高风险有关，其5年累计发生率为(3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P < .001)，多元校正后趋势仍保持一致(危害比 [HR], 2.19; 95% CI, 1.84-2.61, P < .001)。乳房近距离放疗还与较高的感染风险(16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P < .001; adjusted odds ratio [OR], 1.76; 1.64-1.88)及非感染性术后综合症(16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P < .001; 校正后OR值, 2.03; 95% CI, 1.89-2.17)有关；5年累计性乳房疼痛的发生率在接受近距离放疗的患者中比例也较高(14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%)；脂肪坏死发生率也更高(8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%)；肋骨骨折发生率较高(4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; 均P ≤ .01)。乳房近距离放疗组和WBI组5年总体生存率分别为 87.66% (95% CI, 85.94%-89.18%) VS 87.04% (95% CI, 86.69%-87.39%)(校正后 HR值, 0.94; 95% CI, 0.84-1.05; P = .26)。

由此研究者得出结论：在罹患浸润性乳腺癌并接受了肿块切除术的老年妇女中，与全乳房照射相比，近距离放射治疗与乳房长期保全可能性下降及并发症可能性的增加有关，但在总体存活率上则没有差别。

gexiaom

相关文献
Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer.
JAMA 2012;30717:1827-37

Smith GL Xu Y Buchholz TA Giordano SH Jiang J Shih YC Smith BD

Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA. bsmith3@mdanderson.org

Abstract
Brachytherapy is a radiation treatment that uses an implanted radioactive source. In recent years, use of breast brachytherapy after lumpectomy for early breast cancer has increased substantially despite a lack of randomized trial data comparing its effectiveness with standard whole-breast irradiation (WBI). Because results of long-term randomized trials will not be reported for years, detailed analysis of clinical outcomes in a nonrandomized setting is warranted. To compare the likelihood of breast preservation, complications, and survival for brachytherapy vs WBI among a nationwide cohort of older women with breast cancer with fee-for-service Medicare. Retrospective population-based cohort study of 92,735 women aged 67 years or older with incident invasive breast cancer, diagnosed between 2003 and 2007 and followed up through 2008. After lumpectomy 6952 patients were treated with brachytherapy vs 85,783 with WBI. Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ(2) test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test. Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P &lt; .001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84-2.61, P &lt; .001). Brachytherapy was associated with more frequent infectious (16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P &lt; .001; adjusted odds ratio [OR], 1.76; 1.64-1.88) and noninfectious (16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P &lt; .001; adjusted OR, 2.03; 95% CI, 1.89-2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%), fat necrosis (8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%), and rib fracture (4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; P ≤ .01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%-89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%-87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84-1.05; P = .26). In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated worse with long-term breast preservation and increased complications but no difference in survival.