乳房切除重建与年轻女性生活质量 / 开普饭

　　对于低风险早期乳腺癌，乳房切除术与保乳手术相比，虽然局部复发率和长期生存率都相似，但是年轻女性乳腺癌患者的双侧乳房切除术比例仍然持续增加。那么，乳房切除术、乳房重建、保乳手术、放疗等局部治疗对年轻女性乳腺癌患者长期生活质量的影响如何？

　　2021年9月1日，《美国医学会杂志》外科学分册在线发表美国哈佛大学布莱根医院和波士顿妇女医院、达纳法伯癌症研究所、麻省总医院、贝斯以色列和新英格兰女执事医疗中心、梅奥（妙佑）医学中心、康奈尔大学威尔医学院、斯坦福大学、科罗拉多大学癌症中心、韩国蔚山大学首尔峨山医院、加拿大多伦多大学森尼布鲁克健康科学中心的研究报告，探讨了乳房手术和放疗等局部治疗对年轻乳腺癌患者长期满意度和生活质量的影响。

　　该多中心前瞻定群横向研究对2016年10月～2017年11月在北美地区教学医院和社区医院参加年轻女性乳腺癌研究的年龄≥40岁女性进行调查，研究结束后1～2年进行数据分析。根据乳房手术类型、是否重建和放疗，利用BREAST-Q调查问卷对乳房满意度、生理健康、社会心理健康和性健康进行评分；BREAST-Q评分（范围0～100分）较高表明生活质量较好。通过线性回归确定与BREAST-Q各项评分相关的人口统计学因素和临床因素。

　　结果，共计560例0～III期乳腺癌女性（诊断时中位年龄36岁，范围17-40岁，0～II期乳腺癌484例，占86%）于诊断后中位5.8年（范围1.9～10.4年）完成BREAST-Q调查问卷。

　　其中，290例患者（52%）进行双侧乳房切除术，110例患者（20%）进行单侧乳房切除术，160例患者（28%）接受保乳治疗。

　　对于乳房切除术患者，357例（89%）进行重建，181例（45%）接受放疗。

　　单侧或双侧乳房切除术＋放疗与保乳治疗相比，乳房满意度、社会心理健康和性健康评分显著较低（P<0.001），生理健康评分相似（P=0.31）。

　　根据多因素分析，与自体重建相比：

植入物重建：乳房满意度显著较低（β=- 7.4，95%置信区间：-12.8～-2.1，P=0.007）
复杂重建：生理健康评分显著较低（β=-14.0，95%置信区间：-22.2～-5.7，P<0.001）

　　因此，该研究结果表明，对于年轻乳腺癌患者，乳房切除术＋放疗与保乳治疗相比，乳房满意度、社会心理健康和性健康评分显著较低，无论乳房重建与否。植入物重建、复杂重建与自体重建相比，乳房满意度、生理健康评分显著较低。

　　对此，美国纽约纪念医院斯隆凯特林癌症中心乳腺外科主任莫妮卡·莫罗教授发表特邀评论：生活质量与乳腺癌手术。

JAMA Surg. 2021 Sep 1:e213758. Online ahead of print.

Association of Local Therapy With Quality-of-Life Outcomes in Young Women With Breast Cancer.

Dominici L, Hu J, Zheng Y, Kim HJ, King TA, Ruddy KJ, Tamimi RM, Peppercorn J, Schapira L, Borges VF, Come SE, Warner E, Wong JS, Partridge AH, Rosenberg SM.

Brigham and Women's Hospital, Boston, Massachusetts; Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts; Dana-Farber Cancer Institute, Boston, Massachusetts; Massachusetts General Hospital, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Mayo Clinic, Rochester, Minnesota; Weill Cornell Medicine, New York, New York; Stanford University, Palo Alto, California; University of Colorado Cancer Center, Aurora; Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

This cross-sectional study of young breast cancer survivors assesses whether mastectomy is associated with poor quality-of-life outcomes.

QUESTION: What is the longer-term association of surgery with quality of life in young breast cancer survivors?

FINDINGS: In this cross-sectional study of a prospective cohort, unilateral or bilateral mastectomy with radiotherapy (vs breast-conserving therapy) was associated with decreased breast satisfaction and psychosocial and sexual well-being.

MEANING: These findings suggest that more extensive surgery is associated with poorer quality-of-life outcomes in young breast cancer survivors, particularly those treated with mastectomy and radiotherapy, irrespective of reconstruction.

IMPORTANCE: Increasing rates of bilateral mastectomy have been most pronounced in young women with breast cancer, but the association of surgery with long-term quality of life (QOL) remains largely unknown.

OBJECTIVE: To examine the association of surgery with longer-term satisfaction and QOL in young breast cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS: This multicenter cross-sectional study of a prospective cohort was conducted from October 2016 to November 2017, at academic and community hospitals in North America. Women 40 years or older enrolled in the Young Women's Breast Cancer Study were assessed. Data analysis was performed from during a 1- to 2-year period after conclusion of the study.

EXPOSURES: Primary breast surgery, reconstruction, and radiotherapy.

MAIN OUTCOMES AND MEASURES: Mean BREAST-Q breast satisfaction and physical, psychosocial, and sexual well-being scores were compared by type of surgery; higher BREAST-Q scores (range, 0-100) indicate better QOL. Linear regression was used to identify demographic and clinical factors associated with BREAST-Q scores for each domain.

RESULTS: A total of 560 women with stage 0 to III breast cancer (median age at diagnosis, 36 years; range, 17-40 years; 484 [86%] with stage 0-II disease) completed the BREAST-Q a median of 5.8 years (range, 1.9-10.4 years) from diagnosis. A total of 290 patients (52%) of patients underwent bilateral mastectomy, 110 patients (20%) underwent unilateral mastectomy, and 160 patients (28%) received breast-conserving therapy. Among mastectomy patients, 357 (89%) had reconstruction and 181 (45%) received radiotherapy. In multivariate analyses, implant-based reconstruction (vs autologous) was associated with decreased breast satisfaction (β = -7.4; 95% CI, -12.8 to -2.1; P = .007) and complex reconstruction (vs autologous) with worse physical well-being (β = -14.0; 95% CI, -22.2 to -5.7; P < .001).

CONCLUSIONS AND RELEVANCE: These results suggest that local therapy in young breast cancer survivors is persistently associated with poorer scores in multiple QOL domains, particularly among those treated with mastectomy and radiotherapy, irrespective of breast reconstruction. Socioeconomic stressors also appear to play a role.

PMID: 34468718

DOI: 10.1001/jamasurg.2021.3758