| BackgroundBreast cancer is the most common malignant tumor in women,with a high mortality,and surgery is the first choice for breast cancer treatment.With the development of minimally access technology represented by endoscopic and robotic surgery,minimally access surgery has gradually been applied for breast tumors.Previously,a series of clinical observational studies have shown that endoscopic and robotic breast surgeries have the advantages of low intraoperative bleeding,fewer postoperative complications,rapid postoperative recovery,good cosmetic effect,functional preservation,high patient satisfaction,and feasibility.However,due to the lack of data on long-term oncological efficacy,the safety of endoscopic/robotic minimally access surgery in the treatment of breast cancer remains controversial.Therefore,this study compared the long-term efficacy of endoscopic/robotic minimally access breast surgery and conventional breast surgery in breast cancer patients through a long-term follow-up based on previous work.MethodsThis study was a single-center retrospective cohort study collecting basic clinical data of9184 female breast cancer patients in the Department of Breast and Thyroid Surgery,the First Affiliated Hospital of Army Medical University from January 2004 to December 2017.According to the inclusion and exclusion criteria,R software("Match It" package)was used to perform 1:3 propensity score matching(PSM)to balance the differences between the two groups.The patients receiving endoscopic/robotic minimally access surgery were designated as minimally access breast surgery(MABS)group,and the patients receiving conventional breast surgery were designated as conventional breast surgery(CBS)group.Age at diagnosis,lymph node status,pathological stage,pathological type,hormone receptor status,human epidermal growth factor receptor 2(HER2)status,preoperative neoadjuvant chemotherapy,and postoperative adjuvant chemotherapy were used as matching indicators,and the baseline of the two groups was basically the same after matching.The primary endpoint was overall survival(OS),and the secondary outcomes were disease free survival(DFS),local recurrence free survival(LRFS),regional recurrence free survival(RRFS),distant metastasis free survival(DMFS).The Cox univariate and multivariate analysis,and subgroup analysis were performed.The Kaplan-Meier method was used to calculate LRFS,RRFS,DMFS,DFS and OS and the survival curves were plotted,the between-group comparison was tested by log-rank,and the median follow-up time was estimated by the reverse Kaplan-Meier method.The Cox proportional hazard model was used to estimate hazard ratio(HR)and 95% confidence interval(CI),and univariate and multivariate analyses were performed.The R software "forestplot package" was used to plot subgroup analysis forests.The Chi-square test or Fisher’s exact test was used for categorical variables,and the t-test was used for continuous variables.A bilateral truncated P-value<0.05 was considered significantly different.R 4.1.2and SPSS 26 were used for statistical analysis.ResultsAccording to the inclusion and exclusion criteria,a total of 6175 cases were included from 9184 breast cancer patients,including 603 cases in MABS group and 5572 cases in CBS group.After 1:3 PSM,2412 patients were finally included for follow-up,including 603 cases in MABS group(endoscopic,endoscopy-assisted,and robot-assisted breast surgeries in 289,302,and 12 patients,respectively)and 1809 in CBS group.The overall median follow-up was 84 months in all patients,93 months in MABS and 80 months in CBS.MABS compared with CBS in 5-year OS(92.0% vs 93.6%),DFS(85.9% vs 85.0%),LRFS(97.7% vs97.8%),RRFS(97.5% vs 98.2%),and DMFS(90.3.0% vs 88.7%).10-year OS(83.7% vs88.7%),DFS(72.6% vs 76.6%),LRFS(93.3% vs 96.3%),RRFS(95.5% vs 96.7%),and DMFS(81.0% vs 82.0%).15-year OS(83.0% vs 81.0%),DFS(69.1% vs 70.7%),LRFS(91.8% vs94.2%),RRFS(94.2% vs 95.7%),and DMFS(78.3% vs 77.3%).There were no significant differences in OS(HR=1.29,95% CI : 0.97-1.72,P=0.085),DFS(HR=1.07,95% CI :0.86-1.31,P= 0.554),LRFS(HR=1.39,95% CI:0.86-2.27,P=0.182),RRFS(HR=1.38,95% CI:0.81-2.36,P= 0.233)and DMFS(HR=0.95,95% CI:0.74-1.23,P=0.715)between MABS and CBS group(P >0.05).The subgroup analysis showed no significant difference in DFS among subgroups.The subgroup analysis on OS showed that the patients with positive lymph nodes(HR=1.62,95% CI: 1.16-2.28,P=0.005),pathological stage III(HR=1.64,95% CI: 1.03-2.62,P=0.039),preoperative neoadjuvant chemotherapy(HR=1.41,95% CI: 1.04-1.92,P=0.027),postoperative adjuvant chemotherapy(HR=1.35,95% CI: 1.01-1.81,P=0.041)presented a significant difference and the OS of MABS group was significantly lower than that of CBS group.Multivariate analysis showed that positive lymph nodes(HR=1.85,95% CI: 1.39–2.46,P<0.001),pathological stage II(HR=1.37,95% CI: 1.01-1.85,P=0.045),pathological stage III(HR=2.95,95% CI: 2.02-4.32,P <0.001),HER2 positivity(HR=1.37,95% CI: 1.16-1.68,P=0.003),and preoperative neoadjuvant chemotherapy(HR=1.32,95% CI: 1.05-1.67,P=0.019)were risk factors for DFS.Positive lymph nodes(HR=2.91,95% CI: 1.86-4.55,P<0.001),pathological stage III(HR=2.21,95% CI: 1.25–3.91,P=0.006)and preoperative neoadjuvant chemotherapy(HR=1.70,95%CI: 1.18-2.45,P=0.004)were risk factors for OS,and hormone receptor positivity(HR=0.56,95% CI: 0.42-0.74,P<0.001)was a protective factor for OS.ConclusionThrough long-term follow-up,there was no significant difference in the long-term efficacy of MABS or CBS in breast cancer patients.Considering the obvious advantages such as less intraoperative blood loss,fewer postoperative complications,rapid postoperative recovery,good cosmetic effect,functional preservation,and high patient satisfaction,endoscopic/robotic minimally access surgery is a safe and feasible option for breast cancer patients. |
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