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乳腺癌术前靶向化疗性价比与生活质量

  对于HER2阳性早期乳腺癌患者,术前新辅助治疗获得病理完全缓解手术时仍有残癌相比,复发较少、生存结局较好。不过,近期研究数据表明,恩美曲妥珠单抗T-DM1辅助治疗可以改善HER2阳性早期乳腺癌术后残癌患者的生存结局。

  2020年3月17日,施普林格自然旗下《乳腺癌研究与治疗》在线发表美国哈佛大学医学院、达纳法伯癌症研究所、布莱根医院和波士顿妇女医院、耶鲁大学公共卫生学院的研究报告,对HER2阳性早期乳腺癌术前新辅助化疗+抗HER2靶向治疗方案的成本与效益之比和生活质量进行了比较。

  该研究首先结合药物毒性和疾病复发等因素建立HER2阳性II~III期乳腺癌患者的决策分析模型。随后分别建立激素受体阴性和阳性乳腺癌模型,计算生活质量校正后寿命和5年成本。模拟患者接受以下术前新辅助治疗方案之一:

  • 强化方案

  • TCHP:多西他赛+卡铂+曲妥珠单抗+帕妥珠单抗

  • THP→AC:紫杉醇+曲妥珠单抗+帕妥珠单抗→多柔比星+环磷酰胺

  • THP:紫杉醇+曲妥珠单抗+帕妥珠单抗

  • 简化方案

  • TH:紫杉醇+曲妥珠单抗

  • TP:T-DM1+帕妥珠单抗

  根据术前新辅助治疗的病理缓解情况给予个体化术后辅助治疗方案

  结果,对于强化方案,术前THP与TCHP或THP→AC相比,效果较好、成本较低。当包括简化方案时,术前TH的效果最好、成本最低。

  对于激素受体阴性乳腺癌,术前TH与THP相比,虽然生活质量校正后寿命少0.003年,但是成本低5万5831美元,生活质量校正后寿命每年低1800万美元,THP的成本与效益之比远远高于任何可被接受的卫生经济学临界值。

  对于激素受体阳性乳腺癌,术前TH优于THP。

  因此,该研究结果表明,对于HER2阳性早期乳腺癌女性,术前THP或TH新辅助治疗+术后个体化辅助治疗方案可以减少治疗成本和药物毒性,从而改善生活质量和生存结局

Breast Cancer Res Treat. 2020 Mar 17. [Epub ahead of print]

Neoadjuvant treatment strategies for HER2-positive breast cancer: cost-effectiveness and quality of life outcomes.

M. J. Hassett, H. Li, H. J. Burstein, R. S. Punglia.

Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale School of Public Health, New Haven, CT, USA.

PURPOSE: Achieving a pathologic complete response (pCR) with neoadjuvant therapy for HER2-positive breast cancer is associated with less recurrence and improved clinical outcomes compared to having residual cancer at surgery. However, recent data have demonstrated favorable outcomes for patients with residual HER2-positive cancer who received adjuvant trastuzumab emtansine (TDM-1). Therefore, we sought to determine the optimal chemotherapy/anti-HER2 treatment strategy.

METHODS: We created a decision-analytic model for patients with stage II-III HER2-positive cancer that incorporated utilities based on toxicity and recurrence. We separately modeled hormone receptor-negative (HR-) and positive (HR+) disease and calculated quality-adjusted life years (QALYs) and costs through 5 years. Simulated patients received one of the following neoadjuvant treatments: three 'intensive' regimens (TCHP: docetaxel, carboplatin, trastuzumab, pertuzumab; THP+AC: taxol, trastuzumab, pertuzumab then doxorubicin and cyclophosphamide; THP: taxol, trastuzumab, pertuzumab) and two 'de-escalated' regimens (TH: taxol, trastuzumab; TDM-1) followed by adjuvant treatment based on pathologic response.

RESULTS: Among 'intensive' neoadjuvant strategies, treatment with THP was more effective and less costly than TCHP or THP+AC. When 'de-escalated' strategies were included, TH became the most cost-effective. For HR-negative cancer, TH had 0.003 fewer quality-adjusted life years (QALYs) than THP but was less costly by $55,831, resulting in an incremental cost-effectiveness ratio of over $18M/QALY for THP, well above any threshold. For HR-positive cancer, neoadjuvant TH dominated the THP strategy.

CONCLUSION: An adaptive-treatment strategy beginning with neoadjuvant THP or TH followed by tailoring post-operative therapy reduces treatment costs, and spares toxicity compared to more intensive chemotherapy regimens for women with HER2-positive breast cancer.

KEYWORDS: Breast cancer, HER2neu positive, Neoadjuvant therapy, Cost-effectiveness analysis

DOI: 10.1007/s10549-020-05587-5


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