4月17日,，據(jù)《美國醫(yī)學會雜志》（JAMA）發(fā)表的對3種非轉(zhuǎn)移性前列腺癌放療方法的比較研究結(jié)果，雖然調(diào)強放療(IMRT)比適形放療(CRT)可導致較多患者出現(xiàn)勃起功能障礙,，但仍支持IMRT廣泛用于前列腺癌治療,。與IMRT相比，費用最高的最新質(zhì)子治療方法會產(chǎn)生較多的胃腸道副作用,，且未見療效優(yōu)勢,。
費用較高但靶向性更佳的IMRT已經(jīng)逐漸替代CRT，其應用率從2000年的0.15%增至2008年的95.9%,。然而,，IMRT正面臨著備受關(guān)注且治療費用更高的質(zhì)子治療的競爭。自2007年以來,，多家質(zhì)子治療中心相繼成立,，直接面向消費者的廣告在很大程度上促進了該治療方法的應用。但迄今尚沒有對這些治療方法進行有效性比較研究,。
為此,，北卡羅來納大學教堂山分校的Nathan C. Sheets博士及其同事應用傾向得分方法分析了美國監(jiān)測、流行病學和最終結(jié)果(SEER)數(shù)據(jù)庫登記的12,976例確診男性前列腺癌患者資料,。他們均在2002~2006年接受治療,，其中6,666例為IMRT，6,310例為CRT,。研究者發(fā)現(xiàn),，IMRT治療患者接受附加癌癥治療的比例較CRT治療患者約低20%，絕對風險為2.5 vs. 3.1/100(人·年)(P<0.001),。IMRT治療患者胃腸道疾病和髖骨骨折確診病例明顯較少,，絕對風險分別為13.4 vs. 14.7/100(人·年)和0.8 vs. 1.0/100(人·年)，但勃起功能障礙風險較高,，絕對風險為5.9 vs. 5.3/100(人·年),。此外，對1,368例IMRT或質(zhì)子治療患者進行的小規(guī)模傾向得分匹配比較分析結(jié)果顯示,，IMRT治療患者胃腸道發(fā)病率較低,，絕對風險為12.2 vs. 17.8/100(人·年)，但療效未見組間差異,。
該項以人群為基礎(chǔ)的研究表明,，IMRT相對于CRT而言，能夠改善疾病控制程度且沒有增加副作用風險；但最近日益廣泛用于前列腺癌治療的質(zhì)子治療則沒有顯示出額外益處,。
Sheets博士在2月份由美國臨床腫瘤學會,、美國放射腫瘤學學會和泌尿腫瘤學學會聯(lián)合主辦的生殖泌尿腫瘤研討會上報告了上述結(jié)果。該研究結(jié)果以及另外一項針對體外放射治療,、前列腺切除術(shù)和近距離放療的比較研究引發(fā)了有關(guān)新技術(shù)成本效益的討論,。
該研究由美國醫(yī)療保健研究與質(zhì)量局(AHRQ)資助，論文發(fā)表得到國立護理研究所(NINR)資助,。2位共同作者報告與制藥公司存在利益關(guān)系,。（生物谷Bioon.com）
doi:10.1001/jama.2012.460
PMC:
PMID:
Intensity-Modulated Radiation Therapy, Proton Therapy, or Conformal Radiation Therapy and Morbidity and Disease Control in Localized Prostate Cancer
Nathan C. Sheets, MD; Gregg H. Goldin, MD; Anne-Marie Meyer, PhD; Yang Wu, PhD; YunKyung Chang, PhD; Til Stürmer, MD, PhD; Jordan A. Holmes, BS; Bryce B. Reeve, PhD; Paul A. Godley, MD, PhD; William R. Carpenter, PhD; Ronald C. Chen, MD, MPH
Context There has been rapid adoption of newer radiation treatments such as intensity-modulated radiation therapy (IMRT) and proton therapy despite greater cost and limited demonstrated benefit compared with previous technologies.
Objective To determine the comparative morbidity and disease control of IMRT, proton therapy, and conformal radiation therapy for primary prostate cancer treatment.
Design, Setting, and Patients Population-based study using Surveillance, Epidemiology, and End Results–Medicare-linked data from 2000 through 2009 for patients with nonmetastatic prostate cancer.
Main Outcome Measures Rates of gastrointestinal and urinary morbidity, erectile dysfunction, hip fractures, and additional cancer therapy.
Results Use of IMRT vs conformal radiation therapy increased from 0.15% in 2000 to 95.9% in 2008. In propensity score–adjusted analyses (N = 12 976), men who received IMRT vs conformal radiation therapy were less likely to receive a diagnosis of gastrointestinal morbidities (absolute risk, 13.4 vs 14.7 per 100 person-years; relative risk [RR], 0.91; 95% CI, 0.86-0.96) and hip fractures (absolute risk, 0.8 vs 1.0 per 100 person-years; RR, 0.78; 95% CI, 0.65-0.93) but more likely to receive a diagnosis of erectile dysfunction (absolute risk, 5.9 vs 5.3 per 100 person-years; RR, 1.12; 95% CI, 1.03-1.20). Intensity-modulated radiation therapy patients were less likely to receive additional cancer therapy (absolute risk, 2.5 vs 3.1 per 100 person-years; RR, 0.81; 95% CI, 0.73-0.89). In a propensity score–matched comparison between IMRT and proton therapy (n = 1368), IMRT patients had a lower rate of gastrointestinal morbidity (absolute risk, 12.2 vs 17.8 per 100 person-years; RR, 0.66; 95% CI, 0.55-0.79). There were no significant differences in rates of other morbidities or additional therapies between IMRT and proton therapy.
Conclusions Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal morbidity.
