【原】乳腺癌术后骨转移筛查策略探索

　　骨转移是乳腺癌术后远处转移发生率最高的部位。不过，乳腺癌术后无症状患者的骨扫描筛查是否具有生存获益仍然存在争议。国内外现有各大指南推荐对术后出现骨相关症状的患者进行骨扫描检查，但是不推荐对于无症状患者的筛查，可是相关循证医学证据来源于30年前的临床研究，而当时并无分子分型的概念，也缺乏相应的药物和靶向治疗，因此亟需在现代医学的背景下研究乳腺癌骨转移分子特征、预后影响因素和相应术后骨转移筛查策略，以促进骨转移的早诊早治。

　　2022年11月26日，瑞士巴塞尔《癌症》在线发表北京大学人民医院杨柳、杜炜、胡涛波、刘淼、王殊教授团队以及哈尔滨医科大学附属肿瘤医院蔡莉、中山大学孙逸仙纪念医院刘强、山东大学第二医院余之刚、复旦大学附属肿瘤医院柳光宇等学者共同完成的中华医学会外科学分会乳腺外科学组CSBrS-023研究报告，首次探讨了初始不同分期和分型乳腺癌患者术后骨扫描筛查的预后价值，以及有效的乳腺癌术后骨转移监测模式。

CSBrS-023 (NCT03924609): Impact of Intensive Follow-up for Bone Metastasis on Characteristics and Prognosis of Chinese Breast Cancer Patients: A Multicenter Retrospective Study

　　该多中心真实世界回顾研究回顾收集2005～2013年中国5个医疗中心诊断为乳腺癌骨转移患者1059例，其中304例术后出现骨转移症状之前进行骨扫描，其余755例术后出现骨转移症状之后进行骨扫描，通过倾向评分匹配对基线临床病理因素进行平衡，结局指标为总生存和骨转移后总生存。

　　结果，中位随访6.67年（95%置信区间：6.45～7.21），术后出现骨转移症状之前与之后进行骨扫描的患者相比：

• 中位总生存长1.38年（7.99比6.61年，对数秩P=0.003）
• 骨转移后中位总生存长0.59年（3.16比2.57年，对数秩P=0.003）

　　通过倾向评分匹配对基线临床病理因素进行平衡后，术后出现骨转移症状之前与之后进行骨扫描的患者相比：

• 中位总生存长1.63年（7.88比6.25年，对数秩P=0.006）
• 骨转移后中位总生存长0.66年（3.16比2.50 年，对数秩P=0.002）

　　通过多因素比例风险回归分析对其他临床病理因素进行校正后，术后出现骨转移症状之前与之后进行骨扫描的患者相比：

• 总死亡风险低23%（校正后风险比：0.77，95%置信区间：0.64～0.93，校正后P=0.006）
• 骨转移后总死亡风险低29%（校正后风险比：0.71，95%置信区间：0.60～0.86，校正后P<0.001）

　　术后出现骨转移症状之前进行骨扫描的预后价值始终有利于临床高风险患者总生存，包括年龄小于50岁、II期、组织学分级G3、雌激素受体阴性HER2阴性亚型乳腺癌患者。

　　因此，该多中心真实世界回顾研究结果表明，强化术后骨扫描筛查可显著改善乳腺癌骨转移患者总生存，可能应该被推荐用于术后监测，尤其对于临床高风险患者。该研究历时5年，虽然已经没有太多惊喜，但是能够为乳腺癌患者的术后筛查策略提供一点新证据，在这个不知所措的冬季，也算是一点点小确幸。

Cancers (Basel). 2022 Nov 26;14(23):5835. IF: 6.575

Survival in Breast Cancer Patients with Bone Metastasis: A Multicenter Real-World Study on the Prognostic Impact of Intensive Postoperative Bone Scan after Initial Diagnosis of Breast Cancer (CSBrS-023).

Liu Yang, Wei Du, Taobo Hu, Miao Liu, Li Cai, Qiang Liu, Zhigang Yu, Guangyu Liu, Shu Wang.

Peking University People's Hospital, Beijing, China; Harbin Medical University Cancer Hospital, Harbin, China; Sun Yai-Sen Memorial Hospital, Guangzhou, China; The Second Hospital of Shandong University, Jinan, China; Fudan University Shanghai Cancer Center, Shanghai, China.

The bone scan (BS) is widely used in follow-up to detect bone metastasis (BM) in breast cancer (BC) patients presenting bone-related symptoms after surgery. However, it remains controversial whether asymptomatic BS (intensive postoperative BS) screening could be translated into a survival benefit. Therefore, we conducted this multicenter real-world study to understand the prognostic impact of intensive postoperative BS screening among 1059 Chinese patients with BM during the years 2005-2013. This study showed that intensive postoperative BS screening was an independent prognostic factor and prolonged the survival in patients with BC with BM. The prognostic value of intensive BS screening was consistently favorable for survival in patients at clinical high-risk. These findings suggested that intensive BS screening was important for improving survival, and should be recommended for postoperative surveillance, especially for patients with a high risk of recurrence and metastasis.

The prognostic value of intensive postoperative bone scan (BS) screening, which is performed in asymptomatic patients with breast cancer (BC) after surgery, remained unclear. Patients diagnosed with BC with bone metastasis (BM) from five medical centers in China during the years 2005-2013 were retrospectively collected. Propensity score matching (PSM) was performed to balance the baseline characteristics. The survival outcomes were overall survival (OS) and overall survival after BM (OSABM). Among 1059 eligible patients, 304 underwent intensive postoperative BS while 755 did not. During a median follow-up of 6.67 years (95%CI 6.45, 7.21), intensive postoperative BS prolonged the median OS by 1.63 years (Log-Rank p = 0.006) and OSABM by 0.66 years (Log-Rank p = 0.002). Intensive postoperative BS was an independent prognostic factor for both OS (adjusted HR 0.77, 95%CI 0.64, 0.93, adjusted p = 0.006) and OSABM (adjusted HR 0.71, 95%CI 0.60, 0.86, adjusted p < 0.001). The prognostic value of intensive postoperative BS was consistently favorable for OS among clinical high-risk patients, including those with ages younger than 50, stage II, histology grade G3 and ER-Her2- subtype. This multicenter real-world study showed that intensive postoperative BS screening improved survival for BC patients with BM and should probably be recommended for postoperative surveillance, especially for patients at clinical high-risk.

KEYWORDS: breast cancer; bone metastases; bone scan; follow-up; prognosis; survival

DOI: 10.3390/cancers14235835