双侧乳房切除术通常是不合理的


  【24drs.com】单侧乳房诊断为乳癌的妇女,有许多人最后决定连另一侧的健康乳房都切除,因为误认这样可以减少复发风险。
  
  研究者在JAMA Surgery期刊写道,因为担心复发而决定进行额外的手术,事实上,妇女两侧乳房发生乳癌的临床显著风险相当低。
  
  此外,他们指出,对侧预防性乳房切除术(CPM)并未显示可以降低复发风险。第一作者、Sarah T. Hawley博士表示,妇女们因为担心癌症复发而选择进行CPM,但是这个原因没道理,因为将没有发病的乳房切除并不会降低病灶的复发风险。
  
  Hawley医师指出,名演员安洁丽娜裘莉(Angelina Jolie)切除两侧乳房以预防发生乳癌,在媒体的高度报导之下,会使更多诊断为单侧乳房乳癌的妇女也选择将对侧乳房切除。
  
  她表示,这确实有所影响,但是在安洁丽娜裘莉手术前,这个趋势就已经存在。这个趋势和对发生癌症的担忧与焦虑、担心复发有关,想要尽可能做到预防发生复发,而不幸地造成进行不必要的手术。
  
  Hawley医师等人使用密西根州底特律、加州洛杉矶的「流行病监测及最终结果(Surveillance, Epidemiology, and End Results[SEER])」登记资料,调查在2005年6月至2007年2月间新诊断乳癌的2290名妇女,然后在4年后的2009年6月至2010年2月间再度进行调查。
  
  他们询问这些妇女是否进行过以下几种手术之一:单侧乳房切除、乳房保留手术或者CPM。
  
  这些妇女的平均年龄为59.1岁(范围25-79岁),57%已婚或者有伴侣,59%至少有完成一些大学教育。
  
  研究者分析了诊断有治疗乳癌且未发生复发之1447名妇女的回覆资料。研究者发现,18.9%强烈考虑CPM,并有7.6%接受此项手术。
  
  进行CPM的大部分妇女(68.8%)在基因或家族方面都没有对侧乳癌风险因素;进行CPM的妇女,有80%表示她们进行此项手术的目的是预防乳癌,其中多数妇女(85.9%)也进行了乳房重建手术。
  
  研究者还发现,136个临床实际适用CPM的妇女中,多数(75.7%)选择不要手术。
  
  教育程度越高的妇女,越可能选择进行CPM,诊断时有进行MRI和进行额外手术的可能性越大有关。
  
  Hawley医师表示,越年轻的妇女越可能选择进行CPM。
  
  Hawley医师指出,切除两侧乳房的趋势正在增加,在之前到90年代中期,几乎没有人进行CPM,绝对不是我们现在所看到的趋势,而是或许只有临床适用CPM的妇女才进行手术。妇女们甚至不会考虑它,手术率这么低也使它未被列入资料。而最近手术比率窜升促使研究者进一步调查以了解发生什么事情。
  
  哈佛医学院、达那法柏癌症研究院的Ann H. Partridge医师表示,医师应在诊断时即告知病患相关风险。
  
  Partridge医师和Shoshana M. Rosenberg医师共同撰写编辑评论,他们写道,「不可伤害(do no harm)」存在著一层紧张关系,因为缺乏有关复发和存活的利益,CPM被视为无医疗必要,而须尊重病患偏好与自主。
  
  Partridge医师受邀访问时表示,理想上,医师应充分告知病患疾病风险,包括患侧乳房之复发、健侧乳房新发生以及远距复发等,而远距复发的风险通常最大,需要时应给予化疗和荷尔蒙治疗。
  
  Partridge医师表示,需厘清的是,切除健侧乳房并无明确的存活利益。不过,对于某些妇女,确实有道理这样做。无论如何,都必须关注并处理病患的焦虑,否则病患或其亲属都难以接受。
  
  有遗传倾向发生乳癌的妇女(例如有BRCA1或BRCA2突变者、或有其它新发生乳癌高风险,如胸部照射X光者),通常会被谘商建议考虑在诊断有乳癌时同时切除两侧乳房,因为新发生乳癌风险高,未来5年发生率约为20%,而其它没有这些风险的一般存活者未来5年发生率为大约2.5%。
  
  Partridge医师指出,决定进行CPM是妇女及其亲属相当个人化的决定,但有医疗和心理等诸多因素参杂。
  
  资料来源: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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