雙側乳房切除術通常是不合理的


  【24drs.com】單側乳房診斷為乳癌的婦女,有許多人最後決定連另一側的健康乳房都切除,因為誤認這樣可以減少復發風險。
  
  研究者在JAMA Surgery期刊寫道,因為擔心復發而決定進行額外的手術,事實上,婦女兩側乳房發生乳癌的臨床顯著風險相當低。
  
  此外,他們指出,對側預防性乳房切除術(CPM)並未顯示可以降低復發風險。第一作者、Sarah T. Hawley博士表示,婦女們因為擔心癌症復發而選擇進行CPM,但是這個原因沒道理,因為將沒有發病的乳房切除並不會降低病灶的復發風險。
  
  Hawley醫師指出,名演員安潔麗娜裘莉(Angelina Jolie)切除兩側乳房以預防發生乳癌,在媒體的高度報導之下,會使更多診斷為單側乳房乳癌的婦女也選擇將對側乳房切除。
  
  她表示,這確實有所影響,但是在安潔麗娜裘莉手術前,這個趨勢就已經存在。這個趨勢和對發生癌症的擔憂與焦慮、擔心復發有關,想要盡可能做到預防發生復發,而不幸地造成進行不必要的手術。
  
  Hawley醫師等人使用密西根州底特律、加州洛杉磯的「流行病監測及最終結果(Surveillance, Epidemiology, and End Results[SEER])」登記資料,調查在2005年6月至2007年2月間新診斷乳癌的2290名婦女,然後在4年後的2009年6月至2010年2月間再度進行調查。
  
  他們詢問這些婦女是否進行過以下幾種手術之一:單側乳房切除、乳房保留手術或者CPM。
  
  這些婦女的平均年齡為59.1歲(範圍25-79歲),57%已婚或者有伴侶,59%至少有完成一些大學教育。
  
  研究者分析了診斷有治療乳癌且未發生復發之1447名婦女的回覆資料。研究者發現,18.9%強烈考慮CPM,並有7.6%接受此項手術。
  
  進行CPM的大部分婦女(68.8%)在基因或家族方面都沒有對側乳癌風險因素;進行CPM的婦女,有80%表示她們進行此項手術的目的是預防乳癌,其中多數婦女(85.9%)也進行了乳房重建手術。
  
  研究者還發現,136個臨床實際適用CPM的婦女中,多數(75.7%)選擇不要手術。
  
  教育程度越高的婦女,越可能選擇進行CPM,診斷時有進行MRI和進行額外手術的可能性越大有關。
  
  Hawley醫師表示,越年輕的婦女越可能選擇進行CPM。
  
  Hawley醫師指出,切除兩側乳房的趨勢正在增加,在之前到90年代中期,幾乎沒有人進行CPM,絕對不是我們現在所看到的趨勢,而是或許只有臨床適用CPM的婦女才進行手術。婦女們甚至不會考慮它,手術率這麼低也使它未被列入資料。而最近手術比率竄升促使研究者進一步調查以瞭解發生什麼事情。
  
  哈佛醫學院、達那法柏癌症研究院的Ann H. Partridge醫師表示,醫師應在診斷時即告知病患相關風險。
  
  Partridge醫師和Shoshana M. Rosenberg醫師共同撰寫編輯評論,他們寫道,「不可傷害(do no harm)」存在著一層緊張關係,因為缺乏有關復發和存活的利益,CPM被視為無醫療必要,而須尊重病患偏好與自主。
  
  Partridge醫師受邀訪問時表示,理想上,醫師應充分告知病患疾病風險,包括患側乳房之復發、健側乳房新發生以及遠距復發等,而遠距復發的風險通常最大,需要時應給予化療和荷爾蒙治療。
  
  Partridge醫師表示,需釐清的是,切除健側乳房並無明確的存活利益。不過,對於某些婦女,確實有道理這樣做。無論如何,都必須關注並處理病患的焦慮,否則病患或其親屬都難以接受。
  
  有遺傳傾向發生乳癌的婦女(例如有BRCA1或BRCA2突變者、或有其他新發生乳癌高風險,如胸部照射X光者),通常會被諮商建議考慮在診斷有乳癌時同時切除兩側乳房,因為新發生乳癌風險高,未來5年發生率約為20%,而其他沒有這些風險的一般存活者未來5年發生率為大約2.5%。
  
  Partridge醫師指出,決定進行CPM是婦女及其親屬相當個人化的決定,但有醫療和心理等諸多因素參雜。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7083&x_classno=0&x_chkdelpoint=Y
  

Double Mastectomies Often Done for No Reason

By Fran Lowry
Medscape Medical News

Many women diagnosed with breast cancer in 1 breast eventually decide to have the other, healthy breast removed, in the mistaken belief that doing so will reduce their risk for recurrence.

While fear of recurrence appears to drive the decision to undergo the additional surgery, the fact is that relatively few women actually have a clinically significant risk of developing cancer in both breasts, say researchers writing in JAMA Surgery.

Moreover, contralateral prophylactic mastectomy (CPM) has not been shown to reduce the risk for recurrence, they add. "Women appear to be using worry about their cancer recurring as a reason to choose CPM, but this does not make sense because having a nonaffected breast removed will not reduce the risk of recurrence in the affected breast," lead author Sarah T. Hawley, PhD, MBA, told Medscape Medical News.

The Angelina Jolie Factor

When the actress Angelina Jolie had both breasts removed as prophylaxis against developing breast cancer, the widespread media attention may have contributed to more women diagnosed with unilateral breast cancer opting to have the contralateral breast removed as well, Dr. Hawley noted.

"I think that certainly contributed to it, but the trend was already there before she had her surgery. The reason for this trend is related to fear and anxiety about having cancer, worry that it will come back, and having the opportunity to feel as if you are doing everything possible to prevent that, which unfortunately often means having more surgery," she said.

Dr. Sarah T. Hawley

Using Surveillance, Epidemiology, and End Results (SEER) registries in Detroit, Michigan, and Los Angeles, California, Dr. Hawley and her group surveyed 2290 women newly diagnosed with breast cancer from June 2005 to February 2007 and again 4 years later, from June 2009 to February 2010.

They asked the women whether they had received 1 of the following types of surgery: unilateral mastectomy, breast conservation surgery, or CPM.

The mean age of the women was 59.1 years (range, 25 to 79 years), 57% were married or had a partner, and 59% had at least some college education.

The researchers analyzed the responses of 1447 of the women who had been treated for breast cancer and who had not had a recurrence.

They found that 18.9% strongly considered CPM, and 7.6% received it.

The majority of the women (68.8%) who underwent CPM had no genetic or familial risk factors for contralateral breast cancer.

Eighty percent of the women who had CPM said they did so to prevent breast cancer in the other breast. Most of these women (85.9%) also had breast reconstruction surgery.

The researchers also found that of the 136 women who actually had a clinical indication for CPM, most (75.7%) elected not to have the procedure.

Women with more education were more likely to opt for CPM, and t having MRI at the time of diagnosis was associated with a greater likelihood of undergoing the additional surgery.

Younger women were also more likely to opt for CPM, Dr. Hawley said.

Rates of CPM "Inching Up"

The trend for having both breasts removed has been increasing, Dr. Hawley said.

"In the early to mid-90s, almost nobody was having that procedure done, certainly not at the rate that we are seeing now, and perhaps just in the women who have clinical indications for CPM. It just wasn't something women would even think about, it was something that wouldn't even make it into the data because the rate was so low. The fact that the rate is inching up is a cause for further investigation to try and understand what's going on," she said.

Ann H. Partridge, MD, MPH, from the Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, told Medscape Medical News that doctors should be informing patients about their risks at the time of diagnosis.

Dr. Partridge coauthored an accompanying editorial with colleague Shoshana M. Rosenberg, ScD, MPH. They write, "An underlying tension exists between 'do no harm,' viewing CPM as medically unnecessary given the lack of demonstrated benefit on recurrence and survival, and respect for patient preferences and autonomy."

Elaborating In an interview with Medscape Medical News, Dr. Partridge said, "Ideally, clinicians should be telling their patients fully about their risks of disease, including recurrence in the affected breast, new primary in the unaffected breast, as well as distant recurrence, which is usually the greatest risk and the one we give chemo and hormonal therapy for when needed."

The lack of clear survival advantage from taking off the unaffected side needs to be clarified, Dr. Partridge said.

However, for some women, "it makes sense to do this anyway. Regardless, all of this needs to be in a setting where anxiety is addressed and managed with the patient, otherwise it will be difficult for her and her loved ones to digest any of it," she said.

Women who have a genetic predisposition to breast cancer (eg, those with BRCA1 or BRCA2 mutations or who have other high risk factors for a new breast cancer in the other breast, such as having had radiation to the chest), are often counseled to consider bilateral mastectomy at the time of a breast cancer diagnosis because the risk for a new primary cancer is so high, about 20% in the next 5 years compared with about 2.5% in the average survivor, she said.

Dr. Partridge added that the decision to undergo CPM is a "very personal one for a woman and her loved ones to make, with lots of factors both medical and psychological that play into it."

The study was funded by grants to the University of Michigan from the National Institutes of Health. Dr. Hawley, Dr. Rosenberg, and Dr. Partridge have disclosed no relevant financial relationships.

JAMA Surg. Published online May 21, 2014.

    
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