A network meta-analysis of surgical treatment in patients with early breast cancer
A partir d'une revue systématique de la littérature publiée entre 1989 et 2017 (36 études ; 24 702 patientes), cette méta-analyse compare, du point de vue de la survie globale et de la survie sans maladie, l'efficacité de plusieurs stratégies chirurgicales chez les patientes atteintes d'un cancer du sein de stade précoce
Background : In the early breast cancer treatment, the preferred surgical regimen remains a topic of controversy, and conventional pair wise meta-analysis cannot provide a hierarchy based on the clinical trials evidence. Therefore, a network meta-analysis was performed for both direct and indirect comparisons and to assess the survival outcomes of surgical regimens. Methods : Randomized clinical trials comparing different surgical regimens for the treatment of early breast cancer were identified. Overall-survival (OS) and disease-free-survival (DFS) were analysed using random-effects network meta-analysis on the hazard ratio (HR)-scale and calculated as combined HRs and 95% confidence intervals (CIs). All statistical tests were two-sided. Results : The network meta-analysis compared 11 different surgical regimens that consisted of 13 and 17 direct comparisons between strategies for OS (34 trials; n = 23,587 patients) and DFS (32 trials; n = 22,552 patients), respectively. The values of surface under the cumulative ranking (SUCRA) for OS and DFS after mastectomy (M)+radiotherapy (RT) were observed to be the largest. Breast-conserving surgery (BCS)+axillary node sampling (ANS)+RT almost achieved the threshold for inferiority compared with the other surgical treatment arms and was statistically significantly associated with worse OS (HR = 0.51, 95% CI = 0.24 to 0.94; HR = 0.48, 95% CI = 0.22 to 0.92; HR = 0.51, 95% CI = 0.23 to 0.96). No statistically significant difference between BCS+sentinel lymph node biopsy (SLNB)+RT vs BCS+SLNB+intraoperative radiotherapy (IORT) were observed on carrying out network meta-analysis(HR = 0.95, 95% CI = 0.64 to 1.36). Conclusions : M+RT is safer than other surgical regimens for the treatment of early breast cancer patients due to the favorable balance between the survival outcomes. The early breast cancer patients who receive BCS should be given SLNB and not ANS. IORT is no better than postoperative RT in patients who receive SLNB.