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ACSO乳腺癌指南更新

2015-03-13 佚名 医学界

目前,绝大多数乳腺癌属于激素受体阳性乳腺癌,如接近60%~75%患者为雌激素受体阳性(ER+),65%患者为孕激素受体阳性(PgR+)。而辅助内分泌治疗几乎对所有ER+和(或)PgR+乳腺癌有效,已在发达国家和发展中国家患者中得到广泛应用。 近10年,他莫昔芬治疗5年被公认为激素受体阳性乳腺癌辅助内分泌治疗的标准治疗方案。近期,芳香化酶抑制剂成为绝经后女性患者替代他莫昔芬或他莫昔芬后续治

目前,绝大多数乳腺癌属于激素受体阳性乳腺癌,如接近60%~75%患者为雌激素受体阳性(ER+),65%患者为孕激素受体阳性(PgR+)。而辅助内分泌治疗几乎对所有ER+和(或)PgR+乳腺癌有效,已在发达国家和发展中国家患者中得到广泛应用。

近10年,他莫昔芬治疗5年被公认为激素受体阳性乳腺癌辅助内分泌治疗的标准治疗方案。近期,芳香化酶抑制剂成为绝经后女性患者替代他莫昔芬或他莫昔芬后续治疗的新选择。

继2002、2003、2004、2010年美国临床肿瘤学会(ACSO)激素受体阳性乳腺癌女性患者临床实践指南重点更新后,指南制定专家组汇总分析了2009年1月至2013年6月间发表的相关随机临床试验结果以及3项历史研究后,于2014年5月27日在《临床肿瘤学杂志》正式发布新版指南重点更新。

主旨问题:回答激素受体阳性乳腺癌患者辅助内分泌治疗的推荐疗程。

读者对象:内科、外科和放射肿瘤医生,肿瘤科护士和医师助理,妇产科医生,全科医生,Ⅰ~Ⅲ期激素受体阳性乳腺癌女性患者。

方法学:指南更新委员会在系统回顾循证医学文献的基础上形成临床实践指南建议。

治疗建议

Ⅰ:确诊激素受体阳性乳腺癌女性患者在绝经期前或围绝经期应接受辅助内分泌治疗:

ⅠA:初始他莫昔芬治疗疗程为5年。

ⅠB:治疗5年后,根据患者的绝境状态,辅以其他治疗。

ⅠB1:确诊激素受体阳性乳腺癌女性患者处于绝经期前、围绝经期,或不知晓、不确定绝经状态时,应持续予他莫昔芬治疗,总疗程为10年(类型:循证;证据质量:高级;推荐强度:强)。

ⅠB2:确诊激素受体阳性乳腺癌女性患者明确为绝经后,应予持续他莫昔芬治疗10年,或改用芳香化酶抑制剂治疗5年,辅助内分泌治疗总疗程为10年(类型:循证;证据质量:高级;推荐强度:强)。

Ⅱ:确诊激素受体阳性乳腺癌女性患者如已绝经,可选择以下辅助内分泌治疗方案:

ⅡA:他莫昔芬维持治疗10年(类型:循证;证据质量:高级;推荐强度:强);

ⅡB:芳香化酶抑制剂治疗疗程为5年,现有证据尚不足以支持持续治疗超过5年(类型:循证;证据质量:高级;推荐强度:强);

ⅡC:(初始他莫昔芬治疗持续5年,而后换用芳香化酶抑制剂治疗5年,总辅助内分泌治疗疗程为10年(类型:循证;证据质量:高级;推荐强度:强);

ⅡD:他莫昔芬治疗2~3年后改为芳香化酶抑制剂治疗5年,总辅助内分泌治疗疗程为7~8年(类型:循证;证据质量:高级;推荐强度:强)。

Ⅲ:确诊激素受体阳性乳腺癌女性患者如已绝经但不能耐受他莫昔芬或芳香酶抑制剂,可予辅助内分泌治疗:

ⅢA:接受芳香化酶抑制剂治疗但中断疗程不足5年的女性患者,或可予他莫昔芬,总疗程为5年(类型:非正式共识;证据质量:低级;推荐强度:弱);


ⅢB:接受他莫昔芬治疗2~3年的女性患者,可改用芳香化酶抑制剂治疗5年,总辅助内分泌治疗疗程为7~8年(类型:循证;证据质量:高级;推荐强度:强)。

Ⅳ:接受他莫昔芬治疗已达5年患者,应予其他辅助内分泌治疗:

ⅣA:对于绝经的女性患者,可持续予他莫昔芬治疗直至总疗程达10年,或改用芳香化酶抑制剂治疗5年,总辅助内分泌治疗疗程为10年(类型:循证;证据质量:高级;推荐强度:强);

ⅣB:对于绝经期前、围绝经期或绝经状态无法确定的女性患者,应继续予他莫昔芬治疗5年,总辅助内分泌治疗疗程为10年(类型:循证;证据质量:高级;推荐强度:强)。

权衡利弊:


益处:改善总生存期和无远处转移生存期,降低乳腺癌特异性死亡率,降低疾病复发率,降低对侧乳腺癌风险。

风险:子宫内膜癌(如果继续应用他莫昔芬),潮热和其他绝经期症状(应用他莫昔芬或芳香化酶抑制剂),深静脉血栓或肺栓塞(应用他莫昔芬),缺血性心脏病(应用芳香化酶抑制剂),子宫癌(他莫昔芬)。

关键更新:

他莫昔芬治疗疗程从5年延长至10年。

专家观点:

美国马里兰大学医学院Katherine H.R. Tkaczuk认为,指南更新建议肯定了辅助内分泌治疗对绝经前和绝经后的激素受体阳性乳腺癌患者的疗效和总耐受性。“我个人认为,更长期治疗利大于弊,后者中肺栓塞、子宫内膜癌有所增加,但缺血性心脏病发生率变化较复杂且尚无定论,且未影响脑卒中发作。”

美国癌症协会Len Lichtenfeld指出,近期临床证据表明延长他莫昔芬治疗疗程可延长患者生存期,而且有益于防止原发性乳腺癌复发。“但在临床实践中,临床医生和患者还需协商制定最佳治疗方案。”

美国马萨诸塞州总医Michaela J. Higgins表示,所有激素受体阳性乳腺癌患者均需接受辅助内分泌治疗5年,可耐受患者应继续延长内分泌治疗疗程。“对于他莫昔芬治疗5年后仍未绝经患者,现有证据支持继续他莫昔芬维持治疗5年。遇到绝经后或他莫昔芬治疗期间绝经患者,我更愿意选择芳香化酶抑制剂(弗隆),因其不良反应少于他莫昔芬。”

美国科罗拉多大学癌症中心Virginia Borges强调,众所周知雌激素受体阳性乳腺癌患者确诊5年后复发概率极高,本次指南更新体现了激素受体阳性乳腺癌治疗领域的重大进展——延长辅助内分泌预防治疗疗程成为可选临床方案,尤其使年轻患者额外获益。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1068504, encodeId=cdc61068504b2, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Tue Nov 09 10:36:51 CST 2021, time=2021-11-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=113577, encodeId=af971135e71e, content=收藏学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160616/IMG5762A3665DC7B3997.jpg, createdBy=df0a1649089, createdName=ys2323, createdTime=Thu Sep 08 10:22:00 CST 2016, time=2016-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1720639, encodeId=50171e20639e1, content=<a href='/topic/show?id=92f8535575' target=_blank style='color:#2F92EE;'>#CSO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=5355, encryptionId=92f8535575, topicName=CSO)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c6132907836, createdName=mgqwxj, createdTime=Sat Apr 25 00:11:00 CST 2015, time=2015-04-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1988214, encodeId=fc76198821419, content=<a href='/topic/show?id=327e563967e' target=_blank style='color:#2F92EE;'>#指南更新#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56396, encryptionId=327e563967e, topicName=指南更新)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=04ce158, createdName=lxg951, createdTime=Wed Apr 08 09:11:00 CST 2015, time=2015-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1797809, encodeId=ffdc1e978090e, content=<a href='/topic/show?id=d4c823e5176' target=_blank style='color:#2F92EE;'>#乳腺癌指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23751, encryptionId=d4c823e5176, topicName=乳腺癌指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73a3403, createdName=weihongyv, createdTime=Thu Oct 01 06:11:00 CST 2015, time=2015-10-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1279083, encodeId=8fc512e908347, content=<a href='/topic/show?id=316d1882bc' target=_blank style='color:#2F92EE;'>#ACS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1882, encryptionId=316d1882bc, topicName=ACS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=102a153, createdName=yaanren, createdTime=Sun Mar 15 05:11:00 CST 2015, time=2015-03-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18239, encodeId=199318239b6, content=内分泌治疗越来越受重视了, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Fri Mar 13 18:14:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2021-11-09 湘雅科教

    已拜读,受益匪浅。

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1068504, encodeId=cdc61068504b2, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Tue Nov 09 10:36:51 CST 2021, time=2021-11-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=113577, encodeId=af971135e71e, content=收藏学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160616/IMG5762A3665DC7B3997.jpg, createdBy=df0a1649089, createdName=ys2323, createdTime=Thu Sep 08 10:22:00 CST 2016, time=2016-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1720639, encodeId=50171e20639e1, content=<a href='/topic/show?id=92f8535575' target=_blank style='color:#2F92EE;'>#CSO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=5355, encryptionId=92f8535575, topicName=CSO)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c6132907836, createdName=mgqwxj, createdTime=Sat Apr 25 00:11:00 CST 2015, time=2015-04-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1988214, encodeId=fc76198821419, content=<a href='/topic/show?id=327e563967e' target=_blank style='color:#2F92EE;'>#指南更新#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56396, encryptionId=327e563967e, topicName=指南更新)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=04ce158, createdName=lxg951, createdTime=Wed Apr 08 09:11:00 CST 2015, time=2015-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1797809, encodeId=ffdc1e978090e, content=<a href='/topic/show?id=d4c823e5176' target=_blank style='color:#2F92EE;'>#乳腺癌指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23751, encryptionId=d4c823e5176, topicName=乳腺癌指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73a3403, createdName=weihongyv, createdTime=Thu Oct 01 06:11:00 CST 2015, time=2015-10-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1279083, encodeId=8fc512e908347, content=<a href='/topic/show?id=316d1882bc' target=_blank style='color:#2F92EE;'>#ACS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1882, encryptionId=316d1882bc, topicName=ACS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=102a153, createdName=yaanren, createdTime=Sun Mar 15 05:11:00 CST 2015, time=2015-03-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18239, encodeId=199318239b6, content=内分泌治疗越来越受重视了, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Fri Mar 13 18:14:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2016-09-08 ys2323

    收藏学习了

    0

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    2015-04-25 mgqwxj
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    2015-03-15 yaanren
  7. [GetPortalCommentsPageByObjectIdResponse(id=1068504, encodeId=cdc61068504b2, content=已拜读,受益匪浅。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6c905475903, createdName=湘雅科教, createdTime=Tue Nov 09 10:36:51 CST 2021, time=2021-11-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=113577, encodeId=af971135e71e, content=收藏学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160616/IMG5762A3665DC7B3997.jpg, createdBy=df0a1649089, createdName=ys2323, createdTime=Thu Sep 08 10:22:00 CST 2016, time=2016-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1720639, encodeId=50171e20639e1, content=<a href='/topic/show?id=92f8535575' target=_blank style='color:#2F92EE;'>#CSO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=5355, encryptionId=92f8535575, topicName=CSO)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c6132907836, createdName=mgqwxj, createdTime=Sat Apr 25 00:11:00 CST 2015, time=2015-04-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1988214, encodeId=fc76198821419, content=<a href='/topic/show?id=327e563967e' target=_blank style='color:#2F92EE;'>#指南更新#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56396, encryptionId=327e563967e, topicName=指南更新)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=04ce158, createdName=lxg951, createdTime=Wed Apr 08 09:11:00 CST 2015, time=2015-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1797809, encodeId=ffdc1e978090e, content=<a href='/topic/show?id=d4c823e5176' target=_blank style='color:#2F92EE;'>#乳腺癌指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=23751, encryptionId=d4c823e5176, topicName=乳腺癌指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=73a3403, createdName=weihongyv, createdTime=Thu Oct 01 06:11:00 CST 2015, time=2015-10-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1279083, encodeId=8fc512e908347, content=<a href='/topic/show?id=316d1882bc' target=_blank style='color:#2F92EE;'>#ACS#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1882, encryptionId=316d1882bc, topicName=ACS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=102a153, createdName=yaanren, createdTime=Sun Mar 15 05:11:00 CST 2015, time=2015-03-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18239, encodeId=199318239b6, content=内分泌治疗越来越受重视了, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Fri Mar 13 18:14:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2015-03-13 lovetcm

    内分泌治疗越来越受重视了

    0

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在家庭中一级亲属中有前列腺癌史的女性患乳腺癌风险可能增加。这是在CANAER在线发表的一项新的研究结果。研究结果显示,临床医生应采取一切癌症的一个完整的家族史—即使是那些异性家族成员—来帮助评估患者患癌症的风险。 有证据表明,患前列腺癌和乳腺癌的风险在同一疾病的家族史的人增加,尤其是一级亲属。然而,很少有关于家庭中乳腺癌和前列腺癌之间的关系。 为了进行此项研究,底特律芭芭拉•安Karmanos

Cancer:瑜伽有助于减轻乳腺癌患者的围绝经期症状

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