研究發現:乳房切除手術在乳癌治療中未被過度使用


  October 15, 2009 (伊利諾州芝加哥) — 根據發表於10月14日美國醫學會期刊的研究,乳房切除手術在乳癌婦女中未如一般所認為的被過度使用,調查的病患中,約有75%接受乳房保留手術(BCS)作為最初的治療。
  
  第一作者、紐約市Sloan-Kettering紀念癌症中心外科、乳房服務主任Monica Morrow醫師表示,美國兩大都會區中的多數外科醫師,一般建議乳癌病患使用局部治療。
  
  Morrow醫師在一場發表手術照護新研究的記者會中發表這些結果,她向Medscape General Surgery與其他媒體表示,比較貴的檢查,如磁振造影,不太可能是降低乳房切除手術率的原因,因為外科醫師根據體檢和乳房攝影已經可以成功做出判斷。
  
  她們調查乳管原位癌或第一、第二期侵犯乳癌的20至79歲婦女。研究目標是確認最近治療的婦女中,進行乳房切除術的比率、確認她們選擇乳房切除術作為初步治療的原因,以及瞭解病患在嘗試乳房腫瘤切除術之後,有多少會接受乳房切除術。研究樣本來自國家癌症監控、流行病學與最終結果研究中心(SEER)登記資料庫中,加州洛杉磯與密西根州底特律這兩大都會區的資料。幾乎所有的研究對象都是以郵件回覆調查,少數是以電話回覆。
  
  【病患選擇的原因】
  最後的1,984名樣本中,1,468名婦女(74.4%)的最初手術為BCS (包括170名在BCS失敗之後進行乳房切除術者),460人(22.2%)一開始就進行乳房切除術。其他病患並未報告她們的治療選擇。根據作者,第二期的病患比較可能會因為BCS失敗而轉為乳房切除術。
  
  根據作者表示,多數病患在醫師給予最初的治療建議之後,並未尋求其他專家的意見(如果建議的是BCS,則未尋求其他專家意見的比率為97.9%,如果建議的是乳房切除術,則比率為88.8%)。Morrow醫師報告指出,如果病患未接受醫師的特定治療建議,只有三分之一的婦女一開始會選擇乳房切除術。
  
  在341名表示醫師建議進行乳房切除術的婦女中,約有67%對於BCS有醫療上的禁忌,佔整體樣本的11%。她表示,這和其他發現一致,有BCS禁忌的婦女相對較少。
  
  約19%的婦女(n= 378人)考慮其他專家意見。只有43人的其他專家意見和第一位醫師的意見不同,Morrow醫師指出,醫師對於BCS和乳房切除術的適應症有共識。作者們寫道,如果婦女的學歷在高中以上(P< .001),或者醫師建議乳房切除術(P< .001)時,比較會尋求第二專家意見。
  
  根據病患的種族或教育程度分析,第一位醫師建議或病患選擇一開始就進行乳房切除術並無差異。Morrow醫師表示,她們的樣本中有很多黑人和西班牙人,足以代表這些弱勢族群。因為其他研究有納入亞洲人,所以她們的研究排除亞洲人。
  
  【BCS比率似乎是非典型的】
  婦女選擇BCS的比率將近75%,這令一名未參與該研究的外科醫師感到驚訝。伊利諾州芝加哥Rush大學醫學中心乳房外科醫師Alicia Growney向Medscape General Surgery表示,我對這數據如此之高感到驚訝,這顯示,最近認為乳房切除術比率高的想法是錯誤的。
  
  她表示,或者,研究的這兩個醫學中心並未進行高階手術,例如乳房保留之乳房切除術,這會使乳房切除術比率高些。因為此調查僅在美國的兩個地區進行,Growney醫師表示,她希望看到國內其他地區的乳癌手術實務模式。
  
  Growney醫師強調,醫師認為適合乳房腫瘤切除術的病患,未能選用該手術,並非醫師的病患教育失敗,我們應該提供病患所有治療選項,最後由病患決定。
  
  Morrow醫師和Growney醫師皆宣告沒有相關財務關係。

Mastectomy Not Overused for Breast Cancer Treatment, Study Finds

By Kathleen Louden
Medscape Medical News

October 15, 2009 (Chicago, Illinois) — Mastectomy is not being overused in women with breast cancer, as is commonly thought, according to a study published in the October 14 issue of the Journal of the American Medical Association, which found that about 75% of patients surveyed received breast-conserving surgery (BCS) as initial treatment.

"Most surgeons in 2 large diverse urban regions appropriately recommended local therapy options for patients with breast cancer," said lead author Monica Morrow, MD, chief of the breast service, Department of Surgery, at Memorial Sloan-Kettering Cancer Center in New York City.

Dr. Morrow presented the results at a media briefing held to release new research on surgical care. She told Medscape General Surgery and other media that "more expensive testing, such as [magnetic resonance imaging], is unlikely to have an effect on lowering the mastectomy rate, because surgeons already are successful [in doing so] based on physical exam and mammography."

She and her coauthors surveyed women 20 to 79 years with ductal carcinoma in situ or stage I or II invasive breast cancer. The aims of the study were to define the mastectomy rate in a population-based group of recently treated women, to determine why women choose mastectomy as initial breast cancer treatment, and to learn how often patients undergo mastectomy after an attempt at lumpectomy. The sample came from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries for metropolitan Los Angeles, California, and Detroit, Michigan. Nearly all respondents completed the survey by mail, but some completed the survey over the phone.

Reasons for Patient Choices

Of the 1984 women in the final sample, 1468 (74.4%) had BCS as their initial surgery (including 170 who had a mastectomy after an unsuccessful BCS attempt), and 460 (22.2%) had mastectomy initially. The remaining patients did not report their treatment choice. Failure of BCS with "conversion" to mastectomy was more common in patients with stage II cancer, according to the authors.

Most patients who did not get a second opinion followed their surgeon's recommendation for initial treatment (97.9% of women if the recommendation was BCS and 88.8% if the recommendation was mastectomy), according to the authors. One third of patients chose initial mastectomy when they did not receive a specific treatment recommendation from their surgeon, Dr. Morrow reported.

Among the 341 women who reported that their surgeon recommended mastectomy, about 67% had a medical contraindication to BCS, which constituted 11% of the total sample. "This is consistent with other findings that relatively few women have contraindications to BCS," she said.

Approximately 19% of the women (n = 378) sought a second opinion. The second opinion differed from the first opinion for only 43 patients, which Dr. Morrow said indicates that surgeons have adopted consensus thought on indications for BCS and mastectomy. Women were significantly more likely to seek a second opinion if they had more than a high-school education than if they had a high school diploma or less (P < .001) or if the first surgeon recommended mastectomy (P < .001), the authors write.

There were no differences in the first surgeon's recommendation or in the patient's choice for initial mastectomy based on the patient's race/ethnicity or education level. Dr. Morrow said they oversampled blacks and Hispanics to have enough representation of ethnic and racial minorities. They excluded Asians from the study because of enrollment in other studies.

BCS Rate Seems Atypical

The nearly 75% rate of women opting for BCS surprised one surgeon who was not affiliated with the study. "I was surprised it was that high. It shows that the recent perception that we're going back to a higher mastectomy rate is not true," Alicia Growney, MD, a breast surgeon at Rush University Medical Center in Chicago, Illinois, told Medscape General Surgery.

Alternatively, the study's medical centers might not perform advanced procedures, such as nipple-sparing mastectomy, which can result in higher mastectomy rates, she said. Because the survey was conducted in only 2 areas of the United States, Dr. Growney said she would be interested in seeing what the practice patterns are across the country for breast cancer surgery.

Dr. Growney stressed that failure of eligible patients to choose lumpectomy, as recommended by their surgeon, is not the surgeon's failure to properly educate the patient. "We need to offer all the treatment choices to the patient, and in the end, it's up to the patient," she said.

Dr. Morrow and Dr. Growney have disclosed no relevant financial relationships.

JAMA. 2009;302:1551-1556.

    
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