2016年7月21日，《美国医学会杂志肿瘤学分册》在线发表达纳-法伯癌症研究所、哈佛医学院、哈佛皮尔格林健保研究所、达特茅斯研究所、盖泽尔医学院、威斯康星大学医学院的研究报告，分析了不同地区导管原位癌治疗强度与乳房保留率的相关性。
导管原位癌保乳术后放疗使用率存在较大地区差异。未行初始放疗的导管原位癌患者，发生乳腺相关二次病变后即使适合保乳术，其中许多仍被乳房切除术替代。
该研究回顾性分析了SEER（监测、流行病学与最终结果）和SEER医保人群数据库，探讨了导管原位癌放疗地区实践模式是否影响这些患者乳房切除术使用率。数据来自1990～2011年SEER数据库中的2679例确诊导管原位癌女性、1991～2009年SEER医保数据库中的757例确诊导管原位癌女性，中位年龄分别为64（±13）岁和79（±6）岁，未行导管原位癌放疗，并在随后确诊乳腺癌或导管原位癌。
原发性导管原位癌治疗强度的定义，是根据放疗使用率，将医疗服务地区划分为3组（高，中，低）。
乳房切除术对比保乳术的乳腺相关二次病变，定义为导管原位癌复发或新发浸润性癌。
结果发现，导管原位癌放疗使用率较高的医疗服务地区居民，发生乳腺相关二次病变后，与保乳术相比，行乳房切除术的可能性增加，即使是那些之前未行导管原位癌放疗的女性。
居住医疗服务地区的放疗使用率最高者与最低者相比，SEER、SEER医保数据库的乳房切除术校正比值比分别为1.43（95%置信区间：1.10～1.85）和1.90（95%置信区间：1.27～2.84），对应于校正后从40.8%增加至49.6%、从38.6%至54.5%。
因此，导管原位癌放疗使用率较高的地区，在发生乳腺相关二次病变时，乳房切除术率增加，尤其是有医保的患者，即使是符合乳房保留条件的患者。该相关性提示，医师相关因素正影响着乳房保留的可能性。
JAMA Oncol. 2016 Jul 21. [Epub ahead of print]
Association of Regional Intensity of Ductal Carcinoma In Situ Treatment With Likelihood of Breast Preservation.
Punglia RS, Cronin AM, Uno H, Stout NK, Ozanne EM, Greenberg CC, Frank ES, Schrag D.
Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard Pilgrim Health Care Institute, Boston, Massachusetts; The Dartmouth Institute, Geisel School of Medicine, Hanover, New Hampshire; University of Wisconsin School of Medicine, Madison.
IMPORTANCE: Large regional variation exists in the use of radiotherapy after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Although patients who do not receive initial radiotherapy for DCIS are candidates for subsequent BCS if they experience a second breast event, many undergo mastectomy instead.
OBJECTIVE: To examine whether regional practice patterns of radiotherapy for DCIS affect the use of mastectomy in these patients.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of population-based databases (Surveillance, Epidemiology, and End Results [SEER] and SEER-Medicare). Data were obtained for 2679 women in SEER with a diagnosis of DCIS between 1990 and 2011 and for 757 women in SEER-Medicare with a DCIS diagnosis between 1991 and 2009 who had not undergone radiotherapy for DCIS and experienced a subsequent breast cancer or DCIS diagnosis.
EXPOSURES: Treatment intensity for primary DCIS (high, medium, low), as defined by separating health service areas (HSAs) into 3 clusters based on radiotherapy use.
MAIN OUTCOMES AND MEASURES: Mastectomy vs BCS at a second breast event defined as DCIS recurrence or new invasive cancer.
RESULTS: The median (SD) ages of the participants was 64 (13) years for the 2679 SEER population and 79 (6) years for the SEER-Medicare cohort. Residence in an HSA characterized by greater radiotherapy use for DCIS increased the likelihood of receiving mastectomy vs BCS at a subsequent breast event, even among women who had not previously received radiotherapy for DCIS. Adjusted odds ratios for receiving mastectomy were 1.43 (95% CI, 1.10-1.85) and 1.90 (95% CI, 1.27-2.84) in SEER and SEER-Medicare databases, respectively, among women residing in an HSA with the greatest radiotherapy use vs the least, corresponding to an adjusted increase from 40.8% to 49.6%, and from 38.6% to 54.5%.
CONCLUSIONS AND RELEVANCE: Areas with more radiotherapy use for DCIS had increased use of mastectomy at the time of a second breast event even among patients eligible for breast conservation. This association suggests that physician-related factors are affecting the likelihood of breast preservation.
PMID: 27442038
DOI: 10.1001/jamaoncol.2016.2164
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