罹患早期侵襲性乳管癌的美國中高齡女性患者接受不同治療方式之復發及存活情形

Recurrence and Survival of Breast Conserving Therapy or Mastectomy for Women Older than 50 Years with Early-stage Invasive Ductal Carcinoma in America.

吳瓔真(Ying-Jhen Wu)

指導教授 ： 翁世峰

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2019年)

摘要

研究目的
乳癌是女性最常罹患的惡性腫瘤，其中又以侵襲性乳管癌最常見，且好發於50歲以上。先前的研究多數探討不同治療方式對長期存活的影響，並未針對短期的存活與復發情形作深入分析。故本研究目的為探討不同手術治療方式: (1)乳房保留手術輔以放射治療(breast conserving therapy, BCT)、(2)單純乳房切除手術(mastectomy alone, MAS)、(3)乳房切除手術再加上放射治療(mastectomy with radiation, MAS+RT)對罹患早期侵襲性乳管癌的中高齡(50歲以上)女性患者之長、短期存活與復發影響。
研究方法
本研究設計為回溯性世代追蹤研究，使用美國流行病監測及最終結果（Surveillance, Epidemiology, and End Results, SEER）資料庫分析2000年至2015年被診斷為早期(T1-2N0-1M0)侵襲性乳管癌的中高齡女性患者。以SAS 9.4版與STATA 13.0版統計軟體，進行 Chi-Square Test、One-way ANOVA、Kaplan-Meier method、 Log-rank tests、Cox proportional hazard model分析。
研究結果
本研究樣本為184,964人，BCT組佔71.6%、MAS組佔25.2%，而MAS+RT組佔3.2%。在存活率的部分，BCT、MAS和MAS+RT組15年的整體存活率為66.74%、46.67%和53.96%(P<0.001)；乳癌特異性存活率為92.09%、85.25%和78.73%(P<0.001)。在死亡風險的部分，MAS組和MAS+RT組的長期整體死亡風險是BCT組的1.47倍(P<0.001)和1.26倍(P<0.001)；長期乳癌死亡風險是1.40倍(P<0.001)和1.27倍(P<0.001)；短期整體死亡風險是2.92倍(P<0.001)和1.20倍(P=0.201)；短期乳癌死亡風險是3.16倍(P<0.001)和1.65倍(P=0.013)。在復發風險的部分，MAS組和MAS+RT組的長期復發風險是BCT組的0.30倍(P<0.001)和0.43倍(P<0.001)；而MAS組的短期復發風險是BCT組1.90倍(P<0.001)，而MAS +RT組與BCT組在短期復發風險無顯著差異。
結論與建議
BCT組的長、短期整體存活率和乳癌特異性存活率均較MAS組和MAS+RT組高。在復發的部分，BCT組的長期復發風險顯著高於其他兩組，但短期復發風險則較低。BCT治療不僅可使患者的傷口較美觀，存活率也沒有比其他兩種治療差，因此早期乳癌患者在選擇治療方式時，可以考慮BCT治療，但要注意術後長期的復發。未來可以臺灣癌症登記的資料分析，探討早期侵襲性乳管癌的患者接受不同治療之存活與復發情形，與美國資料相比較。

關鍵字

SEER ； 早期侵襲性乳管癌 ； 中高齡女性 ； 存活 ； 復發

並列摘要

Purpose
Invasive ductal carcinoma is the most common type of malignant tumor in women ages greater than 50. Most of the previous studies mainly discussed the effects of different treatments on long term survival and hasn’t focused on analyzing the short term survival and recurrence. Therefore, the purpose of this study is to explore the impact of long term and short term survival and recurrence in middle-aged (over 50 years old) female patients suffering from early invasive ductal carcinoma with various kinds of surgical treatments including (1) breast conserving therapy (BCT) (2) mastectomy alone (MAS) and (3) mastectomy with radiation (MAS+RT).
Methods
This retrospective cohort study used the Surveillance, Epidemiology, and End Results (SEER）database to analyze patients. We selected middle-aged female patients who diagnosed with stage T1-2, N0-1M0 primary breast cancer with invasive ductal carcinoma from 2000 to 2015. The statistical analysis were performed with SAS version 9.4 and STATA version 13.0 to conduct Chi-Square Test, One-way ANOVA, Kaplan-Meier method, Log-rank tests, Cox proportional hazard model.
Results
A total of 184,964 patients were included in this study. BCT group accounts for 71.6%, MAS group accounts for 25.2%, and MAS+RT group accounts for 3.2%. The 15-year overall survival rates of patients who received BCT, MAS, and MAS+RT were 66.74%, 46.67%, and 53.96%, respectively(P<0.001); the 15-year breast cancer-specific survival rates were 92.09%, 85.25%, and 78.73%, respectively (P<0.001). According to multivariate analysis results, the long term overall risk of death in MAS group and MAS+RT group were 1.47(P<0.001) times and 1.26 times (P<0.001) higher than in BCT group; the long term breast cancer risk of death were 1.40 times (P<0.001) and 1.27 times (P<0.001); the short term overall risk of death were 2.92 times (P<0.001) and 1.20 times (P<0.001); the short term breast cancer risk of death were 3.16 times (P<0.001) and 1.65 times (P=0.013). The long term risk of recurrence in MAS group and MAS+RT group were 0.30 times (P<0.001) and 0.43 times (P<0.001) lower than in BCT group; the short term risk of recurrence in MAS group was 1.90 times (P<0.001) higher than in BCT group, whereas the short term risk of recurrence made no significant difference between the MAS+RT group and the BCT group.
Conclusion and Suggestion
The long term and short term overall survival rate and breast cancer-specific survival rate of patients in BCT group were higher than in the MAS group and the MAS+RT group. The risk of long-term recurrence was significantly higher in the BCT group than in the other two groups, but the risk of short-term recurrence was lower. BCT not only can make patient’s wounds better-looking, but also with a better survival rates than in the other two treatments. As a result, early breast cancer patients may consider BCT when choosing the treatments, but need to pay attention to long-term recurrence after surgery. In the future, we can compare the database with US by using the data analysis of the Taiwan Cancer Registry to discuss the survival and recurrence in patients with early-stage invasive ductal carcinoma receiving different treatments.

並列關鍵字

SEER ； early-stage invasive ductal carcinoma ； middle-aged women ； survival ； recurrence

參考文獻

Agarwal, S., Pappas, L., Neumayer, L., Kokeny, K., & Agarwal, J. (2014). Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surgery, 149(3), 267-274.

American Cancer Society. (2017). Breast Cancer Facts & Figures 2017-2018. Retrieved from https://www.cancer.org/research/cancer-facts-statistics/breast-cancer-facts-figures.html

American Joint Committee on Cancer. (2018a). Cancer Staging Posters. Retrieved from https://cancerstaging.org/references-tools/quickreferences/Pages/default.aspx

American Joint Committee on Cancer. (2018b). What is Cancer Staging? Retrieved from https://cancerstaging.org/references-tools/Pages/What-is-Cancer-Staging.aspx

Bosma, S. C., van der Leij, F., van Werkhoven, E., Bartelink, H., Wesseling, J., Linn, S., . . . Elkhuizen, P. H. (2016). Very low local recurrence rates after breast-conserving therapy: analysis of 8485 patients treated over a 28-year period. Breast Cancer Research and Treatment, 156(2), 391-400.