老年早期乳腺癌治疗后钼靶监测指南
对于老年早期乳腺癌患者治疗后的乳腺钼靶监测，尤其预计寿命有限时，目前缺乏指导意见。
2021年1月28日，《美国医学会杂志》肿瘤学分册在线发表美国肿瘤临床研究联盟、哈佛大学医学院、达纳法伯癌症研究所、布莱根医院和波士顿妇女医院、贝斯以色列医院和新英格兰女执事医院、纽约纪念医院斯隆凯特林癌症中心、罗彻斯特大学、旧金山加利福尼亚大学、旧金山退伍军人医院、希望之城国家医学中心、圣路易斯华盛顿大学、拉什大学、德克萨斯大学MD安德森癌症中心、北卡罗来纳大学、梅奥医学中心、密歇根大学、比利时鲁汶大学、法国居里学院联合起草的多学科专家组和国际老年肿瘤学会共识声明：老年早期乳腺癌患者治疗后个体化乳腺钼靶监测，以促进年龄≥75岁乳腺癌患者治疗后常规乳腺钼靶监测的个体化决策。
多学科专家组首先对2014年2月1日～2020年6月29日发表的乳腺癌患者治疗后同侧和对侧乳腺癌事件风险以及乳腺钼靶相关利弊文献进行检索和评审，随后制定年龄≥75岁乳腺癌患者治疗后乳腺钼靶监测共识指南草案，再根据美国临床肿瘤学会和世界卫生组织关于制定指南的指南，通过对临床医师小组进行多轮意见征询汇总整理，以及国际老年肿瘤学会严格评审，对指南进行完善并定稿。
结果，文献评审确定大多数老年乳腺癌患者治疗后同侧和对侧乳腺癌事件风险较低，并对乳腺钼靶相关利弊进行总结。
专家组和临床医师小组对乳腺钼靶指南草案进行反复评估，重点围绕乳腺癌事件患者风险、年龄、预计寿命和个人意愿。
最终共识指南推荐：对于预计寿命<5年的乳腺癌治疗后患者，包括有高风险癌症史者，应该停止常规钼靶监测；当预计寿命5～10年时，考虑停止乳腺钼靶监测；当预计寿命>10年时，继续乳腺钼靶监测。
权衡乳腺钼靶监测相关利弊和患者意愿之后，鼓励个体化、医患共同决策，对推荐意见进行以优化定制。
专家组还推荐进行临床乳房检查和钼靶诊断以评估临床发现和症状，并确保对患者继续这些做法。
因此，这些专家指南将推动临床实践提供个体化讨论方案，促进年龄≥75岁及乳腺癌治疗后乳腺钼靶监测的医患共同决策。
JAMA Oncol. 2021 Jan 28. Online ahead of print.
Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement.
Freedman RA, Minami CA, Winer EP, Morrow M, Smith AK, Walter LC, Sedrak MS, Gagnon H, Perilla-Glen A, Wildiers H, Wildes TM, Lichtman SM, Loh KP, Brain EGC, Ganschow PS, Hunt KK, Mayer DK, Ruddy KJ, Jagsi R, Lin NU, Canin B, LeStage BK, Revette AC, Schonberg MA, Keating NL.
Dana-Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts; Alliance for Clinical Trials in Oncology, Boston, Massachusetts; Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Memorial Sloan Kettering Cancer Center, New York, New York; Memorial Sloan Kettering Cancer Center, Commack, New York; University of Rochester School of Medicine and Dentistry, Rochester, New York; University of California, San Francisco, California; Veterans Affairs Health Care System, San Francisco, California; City of Hope, Duarte, California; Washington University School of Medicine, St Louis, Missouri; Rush University Medical College and Cook County Health, Chicago, Illinois; The University of Texas MD Anderson Cancer Center, Houston; University of North Carolina at Chapel Hill, Chapel Hill; Mayo Clinic, Rochester, Minnesota; University of Michigan, Ann Arbor; University Hospitals Leuven, KU Leuven, Leuven, Belgium; Institut Curie, Saint-Cloud, France.
This special contribution reviews the literature on the risk of breast cancer events among breast cancer survivors and the harms and benefits of mammography to develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography in breast cancer survivors 75 years or older.
IMPORTANCE: There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited.
OBJECTIVE: To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older.
EVIDENCE: After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized.
FINDINGS: The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue.
CONCLUSIONS AND RELEVANCE: It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
PMID: 33507222
DOI: 10.1001/jamaoncol.2020.7582