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前列腺癌根治性前列腺切除术与观察等待的比较——29年随访
Radical Prostatectomy or Watchful Waiting in Prostate Cancer — 29-Year Follow-up


Anna Bill-Axelson ... 肿瘤 • 2018.12.13
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局限性前列腺癌治疗根治术还是观察等待

 

陈海昕,王翔*

中日友好医院泌尿外科

*通讯作者

 

局限性前列腺癌患者选择根治手术还是观察等待,长期以来一直存在争议,原因之一是相关的长期随诊的前瞻性临床研究结果不多。2018年12月13日,SPCG-4(Scandinavian Prostate Cancer Group Study Number 4)研究组在《新英格兰医学杂志》(NEJM)上正式发表了该研究长达29年随访后的最新结果。结论表明,根治性手术相对于观察等待策略可使局限性前列腺癌患者显著获益,使前者平均生存期延长2.9年1。这项研究结果为支持手术治疗策略的观点提供了有力证据。

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摘要


背景

对于临床检出局限性前列腺癌的患者,根治性前列腺切除术降低了其死亡率,但有长期随访的随机试验提供的证据很少。

 

方法

1989年10月至1999年2月,我们将695例局限性前列腺癌患者随机分组,分别接受观察等待或根治性前列腺切除术,并且收集了截至2017年的随访数据。我们在意向治疗分析和符合方案分析中估算了全因死亡、前列腺癌死亡和转移的累积发生率,以及相对危险度和95%置信区间,并估算了寿命增加年数。我们利用Cox比例风险模型评估了组织病理学指标的预后价值。

 

结果

截至2017年12月31日,共有根治性前列腺切除术组347例患者中的261例和观察等待组348例患者中的292例死亡;根治性前列腺切除术组71例患者和观察等待组110例患者死于前列腺癌(相对危险度,0.55;95%置信区间[CI],0.41~0.74;P<0.001;风险绝对差异,11.7个百分点;95% CI,5.2~18.2)。为了避免一例全因死亡,需要治疗的人数是8.4人。23年时,根治性前列腺切除术使患者寿命平均增加了2.9年。在接受根治性前列腺切除术的患者中,包膜外扩散患者的前列腺癌死亡风险高达无包膜外扩散患者的5倍,格利森评分>7分患者的前列腺癌死亡风险高达格利森评分≤6分患者的10倍(格利森评分范围是2~10分,评分较高表示癌症侵袭性较强)。

 

结论

临床检出局限性前列腺癌且预期寿命较长的患者受益于根治性前列腺切除术,寿命平均增加了2.9年。格利森评分高和根治性前列腺切除术标本中的包膜外扩散是前列腺癌死亡的强预测因素(由瑞典癌症学会[Swedish Cancer Society]等资助)。





作者信息

Anna Bill-Axelson, M.D., Ph.D., Lars Holmberg, M.D., Ph.D., Hans Garmo, Ph.D., Kimmo Taari, M.D., Ph.D., Christer Busch, M.D., Ph.D., Stig Nordling, M.D., Ph.D., Michael Häggman, M.D., Ph.D., Swen-Olof Andersson, M.D., Ph.D., Ove Andrén, M.D., Ph.D., Gunnar Steineck, M.D., Ph.D., Hans-Olov Adami, M.D., Ph.D., and Jan-Erik Johansson, M.D., Ph.D.
From the Department of Surgical Sciences (A.B.-A., L.H., M.H.), Regional Cancer Center Uppsala Örebro (H.G.), and the Department of Pathology (C.B.), Uppsala University Hospital, Uppsala, the School of Health and Medical Sciences, Örebro University, and the Department of Urology, Örebro University Hospital, Örebro (S.-O.A., O.A., J.-E.J.), the Department of Medical Epidemiology and Biostatistics (H.-O.A.), Karolinska Institutet, Stockholm, and the Division of Clinical Cancer Epidemiology, Sahlgrenska Academy, Gothenburg (G.S.) — all in Sweden; the School of Medicine, Division of Cancer Studies (L.H., H.G.), and the School of Cancer and Pharmaceutical Sciences (L.H.), King’s College London, London; the Department of Urology, Helsinki University Hospital (K.T.), and the Department of Pathology, University of Helsinki (S.N.), Helsinki; the Department of Epidemiology, Harvard T.C. Chan School of Public Health, Boston (H.-O.A.); and the Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo (H.-O.A.). Address reprint requests to Dr. Bill-Axelson at anna.bill.axelson@surgsci.uu.se.

 

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