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由于乳腺钼靶筛查和辅助治疗的最新进步，对筛查和治疗如何影响美国乳腺癌死亡率进行量化，可以指导将来减少疾病负担的决策。那么，筛查和治疗对不同分子学分型乳腺癌死亡率的影响是否不同？ 2018年1月9日，《美国医学会杂志》发表美国斯坦福大学、哈佛大学医学院、哈佛格林医疗卫生研究院、达纳法伯癌症研究院、德克萨斯大学MD安德森癌症中心、威斯康星大学、华盛顿乔治城大学、纽约爱因斯坦医学院、佛蒙特大学、荷兰鹿特丹大学的研究报告，根据雌激素受体（ER）和人表皮生长因子受体2（HER2）分子学分型，评价了筛查和治疗对乳腺癌死亡率减少的影响。 该研究利用癌症干预和监测网络（CISNET）建立的6大模型（达纳法伯、鹿特丹、乔治城和爱因斯坦、安德森、斯坦福、威斯康星和哈佛），输入乳腺钼靶平片与数字化的方式和效果、ER与HER2相关治疗的效果和推广、其他疾病所致死亡率的全国数据，对多个美国出生队列推算了2000～2012年的美国乳腺癌死亡率，比较了2000～2012年30～79岁女性有与无（基线）筛查和治疗的年龄相关乳腺癌死亡率、乳腺癌总死亡率、ER和HER2相关乳腺癌死亡率；死亡率减少按比例分配给筛查和治疗。 根据模型推算：
对于不同分子学分型，筛查与治疗相比，影响比例不同：
因此，根据该模型研究，推算了美国女性的乳腺癌死亡率变化，2000～2012年乳腺癌总死亡率的减少，虽然受到乳腺癌分子学分型的影响，但是与筛查和辅助治疗的进步密切相关。 其中，治疗进步与筛查进步相比，对乳腺癌总死亡率减少的影响更大，尤其对双阳性乳腺癌。 JAMA. 2018 Jan 9;319(2):154-164. Association of Screening and Treatment With Breast Cancer Mortality by Molecular Subtype in US Women, 2000-2012. Sylvia K. Plevritis; Diego Munoz; Allison W. Kurian; Natasha K. Stout; Oguzhan Alagoz; Aimee M. Near; Sandra J. Lee; Jeroen J. van den Broek; Xuelin Huang; Clyde B. Schechter; Brian L. Sprague; Juhee Song; Harry J. de Koning; Amy Trentham-Dietz; Nicolien T. van Ravesteyn; Ronald Gangnon; Young Chandler; Yisheng Li; Cong Xu; Mehmet Ali Ergun; Hui Huang; Donald A. Berry; Jeanne S. Mandelblatt. Stanford University, Stanford, California; Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts; University of Wisconsin-Madison; Georgetown University Medical Center, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; Erasmus MC University Medical Center, Rotterdam, the Netherlands; University of Texas MD Anderson Cancer Center, Houston; Albert Einstein College of Medicine, Bronx, New York; University of Vermont, Burlington. This simulation study estimates reductions in breast cancer mortality associated with screening and treatment by estrogen-receptor and human epidermal growth factor receptor 2 (ERBB2) status. QUESTION: What are the associations of screening and adjuvant treatment with reductions in US breast cancer mortality rates by molecular subtype? FINDINGS: In this study of 6 simulation models that projected US breast cancer mortality trends for women aged 30 to 79 years, advances in treatment, such as use of newer adjuvant therapies, compared with screening advances were associated with greater estimated reductions in overall breast cancer mortality from 2000 to 2012, although the associations varied by breast cancer molecular subtype. MEANING: Simulation modeling estimated that advances in treatment were associated with greater decreases in breast cancer mortality rates than advances in screening, although these associations varied by molecular subtype. IMPORTANCE: Given recent advances in screening mammography and adjuvant therapy (treatment), quantifying their separate and combined effects on US breast cancer mortality reductions by molecular subtype could guide future decisions to reduce disease burden. OBJECTIVE: To evaluate the contributions associated with screening and treatment to breast cancer mortality reductions by molecular subtype based on estrogen-receptor (ER) and human epidermal growth factor receptor 2 (ERBB2, formerly HER2 or HER2/neu). DESIGN, SETTING, AND PARTICIPANTS: Six Cancer Intervention and Surveillance Network (CISNET) models simulated US breast cancer mortality from 2000 to 2012 using national data on plain-film and digital mammography patterns and performance, dissemination and efficacy of ER/ERBB2-specific treatment, and competing mortality. Multiple US birth cohorts were simulated. EXPOSURES: Screening mammography and treatment. MAIN OUTCOMES AND MEASURES: The models compared age-adjusted, overall, and ER/ERBB2-specific breast cancer mortality rates from 2000 to 2012 for women aged 30 to 79 years relative to the estimated mortality rate in the absence of screening and treatment (baseline rate); mortality reductions were apportioned to screening and treatment. RESULTS: In 2000, the estimated reduction in overall breast cancer mortality rate was 37% (model range, 27%-42%) relative to the estimated baseline rate in 2000 of 64 deaths (model range, 56-73) per 100000 women: 44% (model range, 35%-60%) of this reduction was associated with screening and 56% (model range, 40%-65%) with treatment. In 2012, the estimated reduction in overall breast cancer mortality rate was 49% (model range, 39%-58%) relative to the estimated baseline rate in 2012 of 63 deaths (model range, 54-73) per 100000 women: 37% (model range, 26%-51%) of this reduction was associated with screening and 63% (model range, 49%-74%) with treatment. Of the 63% associated with treatment, 31% (model range, 22%-37%) was associated with chemotherapy, 27% (model range, 18%-36%) with hormone therapy, and 4% (model range, 1%-6%) with trastuzumab. The estimated relative contributions associated with screening vs treatment varied by molecular subtype: for ER+/ERBB2-, 36% (model range, 24%-50%) vs 64% (model range, 50%-76%); for ER+/ERBB2+, 31% (model range, 23%-41%) vs 69% (model range, 59%-77%); for ER-/ERBB2+, 40% (model range, 34%-47%) vs 60% (model range, 53%-66%); and for ER-/ERBB2-, 48% (model range, 38%-57%) vs 52% (model range, 44%-62%). CONCLUSIONS AND RELEVANCE: In this simulation modeling study that projected trends in breast cancer mortality rates among US women, decreases in overall breast cancer mortality from 2000 to 2012 were associated with advances in screening and in adjuvant therapy, although the associations varied by breast cancer molecular subtype. DOI: 10.1001/jama.2017.19130
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