Sequential chemotherapy and icotinib as first-line treatment for advanced epidermal growth factor receptor-mutated non-small cell lung cancer

lNTRODUCTlON

Sun SJ, Jiao SC, and Fang J carried out the studies, participated in collecting data, and drafted the manuscript; Han JD and Liu W performed the statistical analysis and participated in its design; Wu ZY, Zhao X,and Yan X participated in the acquisition, analysis, interpretation of data and drafted the manuscript; All authors have read and approved the final manuscript.

Despite the improvement in progression-free survival (PFS) by EGFR-TKIs, acquired resistance inevitably develops after about 10 mo of treatment[3,6]. Due to the complexity of the EGFR-TKI resistance mechanisms[6-8], a combined treatment approach could be used to prevent or delay resistance development[7]. One of the combination therapies of interest and most frequently explored is chemotherapy + TKI. In clinical trials, a combination of chemotherapy and EGFR-TKI (concomitant or intercalated) generally showed improved efficacy compared with EGFR-TKI alone as the first-line treatment for advanced NSCLC[9-13]. Nevertheless, the best combinational strategy remains controversial.

2.1 小鼠血清IL-33、TNF-α檢測結(jié)果 模型組血清中IL-33水平與正常對照組比較明顯降低(P<0.05)。模型組血清中TNF-α水平與正常對照組比較明顯增高(P<0.01)。經(jīng)益氣固本膠囊治療后，其血清中IL-33水平明顯升高，低劑量組差異明顯(P<0.05)，高劑量組差異顯著(P<0.01)；其血清中TNF-α水平明顯降低，低劑量組、高劑量組均與模型組比較，差異均有統(tǒng)計學(xué)意義(P<0.05)。見表1。

In preclinical studies, compared with concurrent administration of gefitinib alone, the sequential administration of pemetrexed or paclitaxel with gefitinib exerted stronger anti-tumor activity by enhancing cell cytotoxicity[14-18]. Sequential chemotherapy followed by maintenance EGFR-TKI therapy may be a potential strategy, as suggested by recent clinical trials[19-21]. Icotinib was suggested to have potential effects and tolerability when used sequentially with chemotherapy[22-24]. Therefore,the present pilot study aimed to evaluate the efficacy and safety of different sequential combinations of chemotherapy (varying cycle number and chemotherapeutic agents), followed by icotinib maintenance

icotinib alone as a first-line treatment for advanced

-mutated NSCLC. The results might help improve the treatment strategies for these patients.

MATERlALS AND METHODS

Study design and patients

This multicenter, open-label, pilot randomized controlled trial (RCT) was conducted in four centers in China between November 2012 and July 2015. The study was carried out according to the principles of the Declaration of Helsinki and the guidelines of the Good Clinical Practice of the International Council for Harmonization. The trial was approved by the ethics committees of General Hospital of People's Liberation Army. All patients signed an informed consent form before any study procedure.

The inclusion criteria were: (1) Age 18-72 years; (2) patients with treatment-na?ve advanced lung cancer having

-sensitive mutation confirmed by pathological examinations; (3) stage IIIB or IV lung cancer; (4) Eastern Cooperative Oncology Group (ECOG) score of 0-2; (5) normal cardiac, liver, and renal functions, and routine blood test results; (6) expected survival ＞ 3 mo; (7) negative urine pregnancy test within 7 d before screening for women of child-bearing age, and agreement to apply effective contraception measures to prevent pregnancy during and within 3 mo after the study for fertile men and women; and (8) signed informed consent forms. The exclusion criteria were: (1) Brain metastases; (2) active infection (according to the judgment of investigators); (3) major organ failure, such as decompensated cardiopulmonary failure; (4) newly developed myocardial infarction or cerebral infarction within 3 mo; (5) presence of a second malignant tumor (except for cured cervical cancer or skin cancer); (6) interstitial lung disease; or (7) pregnant or breastfeeding women.

在生產(chǎn)建設(shè)和百姓用電的過程中，結(jié)合實際需求和增長情況等，在電力系統(tǒng)發(fā)展中，需要明確電力電纜設(shè)備故障以及探測技術(shù)的問題，關(guān)系到電力傳輸?shù)姆€(wěn)定性和安全性，在后續(xù)電纜故障分析的階段，科學(xué)合理實施預(yù)設(shè)。此外先進(jìn)的探測技術(shù)有重要的作用，在電纜故障判斷的過程中，需要發(fā)揮良好的運行性能，保證電力系統(tǒng)的正常供電。

Trial registration: ClinicalTrials.gov, NCT01665417. Registered on August 12, 2012, https://clinicaltrials.gov/ct2/show/NCT01665417.

Randomization and blinding

This study involved three randomizations. The patients were first randomized 2:3 to icotinib-alone

chemotherapy + icotinib. The patients in the chemotherapy group were then randomized 1:1 to two

four cycles of chemotherapy and further randomized 1:1 to pemetrexed and cisplatin (PP)

docetaxel and cisplatin (DP) (Figure 1). All randomizations were carried out using a central randomization system designed by an independent biostatistician. The stratification factors after randomization included clinical stage (IIIB

IV), type of

mutation (exon 19 mutation

exon 21 mutation), ECOG score(0-1

2), and smoking status (non-smokers

mild smokers

regular smokers). This study was a pilot study, and the patients, treating physicians, and data assessors could not be blind to treatment allocation due to the nature of the treatments.

Treatment

Icotinib was provided by Betta Pharmaceutical Co., Ltd. (Zhejiang, China). Two or four cycles of PP(pemetrexed disodium 500 mg/m

iv d1, cisplatin 75 mg/m

iv d1, q3w) or DP (docetaxel 75 mg/m

iv d1, cisplatin 75 mg/m

iv d1, q3w) were administered to the patients assigned to the first-line chemotherapy + icotinib treatment. Icotinib hydrochloride (oral, 125 mg, tid) was used as maintenance therapy or second-line therapy until disease progression or the occurrence of severe toxicity for patients with clinical benefits or progressive disease after chemotherapy. Second-line chemotherapy after disease progression on icotinib was the crossover of the first-line chemotherapy. The chemotherapy regimen after DP/PP treatment had no restriction.

For the patients assigned to first-line icotinib treatment, 125 mg icotinib was administered orally three times per day until disease progression or the occurrence of severe toxicity. For second-line treatment,the patients received the PP (pemetrexed disodium 500 mg/m

iv d1, cisplatin 75 mg/m

iv d1, q3w) or DP (docetaxel 75 mg/m

iv d1, cisplatin 75 mg/m

iv d1, q3w) chemotherapy regimen, at the discretion of the treating physician.

The study's primary endpoint was PFS, defined as the date of the start of treatment to the date of PD(per RECIST 1.1) or death, whichever occurred first. The secondary endpoint was overall survival (OS),defined as the time from the start of treatment to death. Other efficacy endpoints included overall response rate (ORR) and disease control rate (DCR). The ORR was defined as the proportion of patients achieving CR or PR, and the DCR was defined as the proportion of patients achieving CR, PR, or SD.

Assessment

For patients on first-line chemotherapy, the tumor response was assessed after every two cycles of chemotherapy. During icotinib maintenance therapy, treatment efficacy assessment was performed 4 wk after treatment initiation and then every 6 wk until disease progression. For patients on first-line icotinib therapy, tumor response was assessed 4 wk after treatment initiation and then every 6 wk until disease progression. The tumors were assessed by plain and enhanced pulmonary computed tomography (CT) scanning, abdominal ultrasound examination, CT scanning or magnetic resonance imaging (MRI), ultrasound examination of superficial lymph nodes, brain MRI (if necessary), and emission CT (if necessary). The response to treatment was classified as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) according to RECIST 1.1[25]. The safety evaluation was performed using physical examinations and laboratory examinations (hematological and blood biochemical examinations). All adverse events were recorded from the informed consent until 30 d after the last dose of the study drug. The severity of the adverse events was assessed and documented according to the National Cancer Institute-Common Toxicity Criteria 3.0. The investigators judged the relationship between the adverse events and treatment.

Outcomes

在拉斐爾前派短暫的第一烏托邦消亡之后，羅塞蒂的藝術(shù)對后世的影響反而要遠(yuǎn)超從前。如果說此前更多的是以團隊成員的性質(zhì)進(jìn)行藝術(shù)活動的話，那么這段時期的羅塞蒂已經(jīng)完全呈現(xiàn)出自己的個人風(fēng)格了。

Statistical analysis

All analyses were performed using SAS 9.2 (SAS Institute, Inc., NC, United States). The efficacy analysis was performed in the full analysis set, defined as all randomized patients who received at least one dose of the study drug. The safety set included all randomized patients who received at least one dose of the study drug. Continuous data are presented as means ± SD and medians (ranges). Categorical data are presented as numbers (percentages). PFS and OS were analyzed using the Kaplan-Meier method and the log-rank test. The ORR and DCR were summarized as percentages and Clopper-Pearson 95%CIs.Two-sided

values of ＜ 0.05 were considered statistically significant.

RESULTS

Characteristics of the participants

Between November 2012 and July 2015, 68 participants were recruited: 24 in the icotinib-alone group and 44 in the chemotherapy + icotinib group. The participants who received single-dose treatment (22 in the icotinib-alone group and 36 in the chemotherapy + icotinib group) were included in the analysis. All participants were randomized, and treatment was initiated. The characteristics of the participants are shown in Table 1. All patients except one had stage IV NSCLC.

A sequential combination of chemotherapy and EGFR-tyrosine kinase inhibitor is feasible for stage IV

-mutated NSCLC patients.

In the present study, four cycles of chemotherapy were not better in terms of ORR, DCR, PFS, and OS compared with two cycles. Two cycles might be enough to eliminate tumor cells sensitive to chemotherapy and activate the immune system, while four cycles might lead to adverse events and decreases in blood immune cells[43]. In addition, fewer cycles could help reduce the physical, psychological, and economic burden of chemotherapy[43]. The rate of grade ≥ 3 TRAEs was 14.3% in the twocycle subgroup and 15.4% in the four-cycle subgroup. Hence, the present study suggests similar efficacy and safety for the two- and four-cycle regimens, which could be supported by a meta-analysis that suggested no added benefit of six cycles of first-line chemotherapy compared with three and four cycles[43]. However, this study was not powered to compare two-

four-cycle regimens, and additional studies are necessary to examine this point.

Response to treatment

Table 2 shows the responses to treatment. No participants achieved CR. In the icotinib-alone group, the ORR was 54.5% (95%CI: 32.2-75.6) and the DCR was 90.9% (95%CI: 70.8-98.9) compared with 44.1%(95%CI: 27.2-62.1) and 97.1% (95%CI: 84.7-99.9), respectively, in the chemotherapy + icotinib group.

When considering the number of chemotherapy cycles, the ORR was 47.6% (95%CI: 25.7-70.2) and the DCR was 100.0% (95%CI: 83.9-100.0) for two cycles, and the ORR was 38.5% (95%CI: 13.9-68.4) and the DCR was 92.3% (95%CI: 64.0-99.8) for four cycles. When considering the chemotherapy types, the ORR was 40.0% (95%CI: 16.3-67.7) and the DCR was 100.0% (95%CI: 78.2-100.0) for DP, and the ORR was 47.4% (95%CI: 24.4-71.1) and the DCR was 94.7% (95%CI: 74.0-99.9) for PP. When considering each chemotherapy regimen, the ORR was 33.3%-60.0%, and the DCR was 88.9%-100%.

3）三伏貼治療方案：①三伏貼選穴：主穴1：選取大椎、定喘（雙側(cè)）、肺俞（雙側(cè)）；主穴2：膻中、天突。兩組穴位交替敷貼。

Survival

In the icotinib group, the median follow-up was 23.1 (range, 2.5-71.9) mo. The median follow-up in the chemotherapy + icotinib group was 36.0 (range, 5.1-75.7) mo. Figures 2 and 3 present the PFS and OS,respectively. The median PFS in the icotinib-alone and chemotherapy + icotinib groups was 8.0 mo(95%CI: 3.8-11.6)

13.4 mo (95%CI: 10.2-16.3), respectively (

= 0.0249). The median OS was 23.1(95%CI: 9.7-50.3)

36.0 mo (95%CI: 22.2-45.4), respectively (

= 0.4511). The median PFS of the participants who received two and four chemotherapy cycles was 12.1 mo

15.1 mo, and the median OS was 36.1 mo

33.9 mo, with no significant differences (PFS,

= 0.6605; OS,

= 0.9239). The PFS after two cycles of DP, two cycles of PP, four cycles of DP, and four cycles of PP was 11.9, 15.2, 15.2, and 15.1 mo, respectively; the median OS was 36.1, 28.0, 36.1, and 33.9 mo, respectively. No significant difference was observed among the different treatment regimens (PFS,

= 0.1815; OS,

= 0.9549).

Table 3 presents the treatment received after icotinib-based therapy. The treatment profile was similar in the two groups.

阿里很久沒見到母親了，阿里只知道母親在睡覺。他不明白，母親為什么老是睡覺。他想不明白，也問不出來。雖然每天早上他去東湖放錄音，聽母親的聲音，但那到底不是母親。沒有母親溫?zé)岬氖终疲矝]有母親的笑聲，更沒有母親每天跟他說這說那，給他好吃的東西。這個世界跟以前不一樣了。母親一直在睡覺，阿里竟也一直都不進(jìn)她的房間。阿里不能吵她。

Treatment-related adverse events

The rates of all-grade treatment-related adverse events (TRAEs) were lower in the icotinib-alone group compared with the chemotherapy + icotinib group, and included rash (40.9%

55.9%), gastrointestinal system disorders (0.0%

82.4%), alanine transaminase elevation (27.3%

41.2%), aspartate aminotransferase elevation (13.6%

29.4%), leukopenia (0.0%

64.7%), and thrombocytopenia (0.0%

11.8%). Grade 3-4 TRAEs were not observed in the icotinib-alone group. However, grade 3-4 gastrointestinal system disorders (5.9%) and leukopenia (8.8%) were recorded in the chemotherapy +icotinib group (Table 4).

DlSCUSSlON

Sequential chemotherapy followed by maintenance TKI may be a potential strategy for advanced NSCLC with

mutation. However, the optimal regimen remains to be determined. In this study,icotinib was selected because of the potential effect and tolerability of sequential chemotherapy and icotinib[22-24]. The present study indicated that the sequential combination of chemotherapy followed by icotinib improved PFS by 5.4 mo compared with icotinib alone as the first-line therapy of NSCLC. In addition, no differences were observed between two and four cycles of chemotherapy and between PP and DP. Therefore, for patients with advanced NSCLC with

mutation, a sequential combination of chemotherapy and an EGFR-TKI is feasible. Considering the chemotherapy toxicity, the efficacy of a two-cycle chemotherapy regimen was comparable to that of a four-cycle chemotherapy regimen.

In the present study, no significant differences were observed in OS (36 mo

23.1 mo) and PFS (8.0 mo

13.4 mo), which was probably due to the small sample size or the fact of crossover of the treatment group upon disease progression. Considering the synergistic effect of EGFR-TKIs and chemotherapy in the elimination of tumor cells, as reported by some preclinical studies, gefitinib and erlotinib were combined with two chemotherapy regimens (cisplatin + gemcitabine; carboplatin +paclitaxel), thus launching four large phase III clinical studies, including INTACT 1 and 2 and TRIBUTE[26,27]. These studies showed no significant difference between chemotherapy and combined treatment groups (PFS and OS), which might be because the participants were not selected according to their

mutation status[28]. A retrospective analysis of the OPTIMAL study on

mutation (exon 19 deletion or exon 21 L858R mutation) showed that the OS of patients treated with chemotherapy alone was significantly lower than that of patients who received TKI and sequential chemotherapy [median OS: 11.2

29.7 mo, HR = 2.97 (1.74-5.07)]. Although it was a retrospective analysis, it also suggested that sequential treatment with TKI and chemotherapy for selected patients with

mutation could prolong patient OS[29]. However, a phase II clinical study in Japan, NEJ00, reported that in NSCLC patients with

mutation, the combined therapy of gefitinib, pemetrexed, and carboplatin was significantly superior to chemotherapy followed by targeted therapy[30]. Among the 80 enrolled patients, 41 received concurrent combination therapy, while 39 also had sequential therapy. The medianPFS was 18.3 mo

15.3 mo [HR = 0.71 (0.42-1.2),

= 0.02], and median OS was 41.9 mo

30.7 mo [HR= 0.51 (0.26-0.99),

= 0.042], respectively. The response rates in the two groups were similar (87.8% and 84.6%, respectively). Furthermore, phase II clinical studies conducted in China reported similar results for gefitinib combined with pemetrexed-based chemotherapy[31]. Based on the results of NEJ005, the phase III clinical study NEJ009 further confirmed that the efficacy of gefitinib combined with carboplatin and pemetrexed was superior to that of single-drug gefitinib treatment[32], which showed that the PFS was 20.9 mo (18.0-24.2)

11.2 mo (9.0-13.4) [HR = 0.43 (0.39-0.62),

＜ 0.001], and more importantly, OS was 52.2 mo

38.8 mo (HR = 0.69,

= 0.013). Subsequently, CTRI/2016/08/007149,conducted in India and almost completely similar to NEJ009, further confirmed that the efficacy of gefitinib combined with carboplatin and pemetrexed was significantly superior to that of gefitinib alone[33]. It also demonstrated that the PFS of gefitinib combined with pemetrexed-based chemotherapy was longer than 16 mo and longer than 20.9 mo in NEJ009, which was a much longer PFS than achieved by gefitinib alone. In particular, two phase III clinical trials, NEJ009 and CTRI/2016/08/007149, confirmed the benefits of OS in the combination treatment group. The studies mentioned above mainly focused on targeting, a synchronous combination of chemotherapy, or alternating sequential combination of targeting and chemotherapy. However, evidence on the use of sequential therapy based on chemotherapy followed by the target drug in

-mutant patients is lacking. Studies at the molecular level confirmed that sequential chemotherapy with the EGFR-TKI erlotinib after docetaxel could enhance the M-phase stagnation of tumor cell division and growth, resulting in cell apoptosis. They suggested a synergistic effect between molecular targeted therapy and appropriate sequential chemotherapy. These experimental results indicated that the use of chemotherapy first to induce tumor cell stagnation and apoptosis in the M phase, followed by EGFR-TKIs to enhance this effect[34], would result in sequential therapy having a superposition effect, which might be used as a feasible option.Similar to the present study, Han

[13] compared gefitinib + pemetrexed + carboplatin

gefitinib alone

pemetrexed + carboplatin and reported a higher ORR with the TKI + chemotherapycombination than for TKI alone or chemotherapy alone (82.5%

65.9%

32.5%), with similar trends in PFS and OS. Similar results were also reported by Wen

[35] and Yan

[36]. Another RCT focused on first-line chemotherapy and TKI sequential treatment in patients with advanced non-squamous NSCLC[37,38]. PFS and OS were similar in the pemetrexed + cisplatin + gefitinib and gefitinib monotherapy groups in the ITT population and

-mutated subgroup, but the sample size in the

-mutated subgroup was too small to draw a firm conclusion. The combination therapy may outperform the monotherapy ORR as chemotherapy and TKIs do not affect the cancer cells using the same mechanisms (

, hitting the cells in multiple ways), and intratumor heterogeneity may be present(

, using multiple drugs increases the likelihood of killing cells resistant to one of the drugs used). The immune system can also be activated[9,34,39,40]. Nevertheless, the PFS in the sequential treatment group in the present study was superior to that in the TKI-alone therapy group. The reason for the inconsistent results in these two studies might be that the number of patients with

mutation in either study was small, affecting the consistency of the study results. Of note, the recent results of the FLAURA trial showed that first-line osimertinib achieved better OS and PFS than the comparator EGFRTKIs[41], and sequential osimertinib with chemotherapy as a first-line option should be investigated.Due to the TRAE profile of osimertinib, the sequential use of chemotherapy and osimertinib could decrease the occurrence of TRAEs in the first-line treatment of NSCLC. Furthermore, the combination of EGFR-TKIs with vascular endothelial growth factor inhibitors could be a potential strategic option[42]and should also be examined.

從圖8(a)、圖8(b)可以看出，帶內(nèi)誤差補償前，成像場景中強目標(biāo)距離向旁瓣很高，遠(yuǎn)端旁瓣數(shù)值也較高，會遮蓋周圍弱目標(biāo)，成像效果很差。經(jīng)過帶內(nèi)幅度和相位誤差補償后，旁瓣數(shù)值降低十分明顯，遠(yuǎn)端旁瓣對周圍目標(biāo)的影響非常小，成像質(zhì)量得到明顯改善。綜合以上處理結(jié)果可知，子帶內(nèi)幅度和相位誤差得到了有效的補償。

There are many therapeutic options in lung cancer, including chemotherapy, targeted therapy, and immunotherapy[2,44-48]. Icotinib is a promising targeted therapy for

-mutated NSCLC[18,22-24].The present study selected the combination of icotinib (or other EGFR-TKIs) and chemotherapy since it is the most studied combination in NSCLC, with apparent benefits in response and survival[9,18,24,34-36,49]. Still, the combination of EGFR-TKIs and immunotherapy could be a promising option for NSCLC[50-52], but some evidence suggests that immunotherapy is not effective in patients with

mutated NSCLC, probably because of the specific tumor microenvironment[52,53]. Indeed, early trials showed that immunotherapy monotherapy was inferior to EGFR-TKIs in

-mutated NSCLC[52,53]. Subsequent studies showed that the combination of immunotherapy with EGFR-TKIs in

mutated NSCLC resulted in high rates of serious AEs (33.3%-71.4% of grade 3-4 AEs)[54-56]. Therefore,additional studies are necessary before being able to use immunotherapy with EGFR-TKIs in patients with

-mutated NSCLC.

? 插 圖 出 自 L.D.Ettlinger,“The Pictorial Source of Ripa's'Historia'”,Journal of the Warburg and Courtauld Institutes,vol.13,no.3/4,1950,圖版 63。

Roviello

[57] reported that EGFR-TKIs led to good outcomes in older adults with

-mutated NSCLC. We agree that EGFR-TKIs could be a valuable and less toxic treatment option for older adults who often have difficulties with chemotherapy. Unfortunately, in the present study, the sample size was too small to be able to examine the influence of age on the treatment outcomes. Furthermore, as per the inclusion criteria, no patients ＞ 72 years old were enrolled. Nevertheless, examining treatment options specifically in older adults is indeed a future direction for research.

This study had some limitations. This study was an exploratory study with a small sample size, and the analysis of OS had limited power. In addition, it was restricted to Chinese patients. It was an investigator-initiated trial. Only icotinib was provided, and the patients had to pay for the chemotherapy. This could have influenced recruitment. Although the trial was open to stage IIIB-IV patients, only one stage IIIB participant was actually recruited, mostly limiting the conclusions to stage IV patients. Due to the limited generalizability, the efficacy of sequential chemotherapy followed by TKI in the Caucasian population requires further investigation. Whether the results could also be generalized to non-stage IV patients remains to be examined.

CONCLUSlON

For patients with stage IV NSCLC and

mutation, sequential chemotherapy followed by TKI maintenance therapy is feasible. No significant differences were found in terms of the influence of the different number of chemotherapy cycles or different chemotherapy drugs on the curative effect,suggesting that fewer chemotherapy cycles could result in the same therapeutic effect in these specific patients.

ARTlCLE HlGHLlGHTS

FOOTNOTES

Globally, lung cancer is the malignancy with the highest incidence and mortality. In 2018, 2.1 million new lung cancers and 1.8 million deaths were reported, with an annual age-standardized incidence rate of 22.5 per 100000 individuals and an age-standardized yearly mortality rate of 18.6 per 100000 individuals[1]. Non-small cell lung cancers (NSCLCs) represent the greatest number (85%-90%) of malignant lung tumors[2], and almost half of NSCLCs are adenocarcinomas. Adenocarcinomas display activating mutations in the epithelial growth factor receptor (

) gene, making such cancers candidates for EGFR tyrosine kinase inhibitor (EGFR-TKI) therapy[3-5]. In Asians, individuals harboring

mutations account for 51.4% of adenocarcinoma NSCLCs[3-5]. Currently, EGFR-TKIs are the guideline-recommended first-line treatment for advanced NSCLC with

mutations[5].

The study was reviewed and approved by General Hospital of People's Liberation Army.

深化水利建設(shè)與管理體制改革 為水利改革發(fā)展提供堅實保障……………………………………………………… 孫繼昌(23.9)

ClinicalTrials.gov, NCT01665417. Registered on August 12, 2012,https://clinicaltrials.gov/ct2/show/NCT01665417.

All patients signed an informed consent form before any study procedure.

The authors declare no conflicts of interest.

The raw dataset analyzed in the current study are available from the corresponding author on reasonable request.

熵權(quán)法通過收集客觀信息，以事實為基礎(chǔ)進(jìn)行計算，消除了信息之間的重疊性，有很強的說服力。但是未反映研究人員的經(jīng)驗，同時易受離散極值的影響，結(jié)果有時與實際情況不符，難以得到公認(rèn)。

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Sheng-Jie Sun 0000-0001-7010-9472; Jin-Di Han 0000-0002-0790-9802; Wei Liu 0000-0002-1534-1823; Zhi-Yong Wu 0000-0002-8763-4449; Xiao Zhao 0000-0002-8661-1480; Xiang Yan 0000-0002-3683-474X; Shun-Chang Jiao 0000-0001-8017-5342; Jian Fang 0000-0003-3697-4563.

Zhang H

Webster JR

Zhang H

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