中国癌症杂志 ›› 2021, Vol. 31 ›› Issue (8): 689-696.doi: 10.19401/j.cnki.1007-3639.2021.08.001

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激素受体阳性早期乳腺癌治疗现状与挑战

丛斌斌,王永胜   

  1. 山东省肿瘤防治研究院(山东省肿瘤医院),山东第一医科大学(山东省医学科学院)乳腺病中心,山东 济南 250117
  • 出版日期:2021-08-30 发布日期:2021-09-03
  • 通信作者: 王永胜 E-mail: wangysh2008@aliyun.com
  • 基金资助:
    北京医学奖励基金(YXJL-2020-0941-0762, YXJL-2020-0941-0740)。

Treatment landscape and challenges of managing the hormone receptor-positive early breast cancer

CONG Binbin, WANG Yongsheng   

  1. Department of Breast Cancer Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, Shandong Province, China
  • Published:2021-08-30 Online:2021-09-03
  • Contact: WANG Yongsheng E-mail: wangysh2008@aliyun.com

摘要: 在早期发现、有效治疗的情况下,早期乳腺癌是可治愈的,长期无病生存应是早期患者所追求的治疗目标。既往认为乳腺癌各亚型中激素受体(hormone receptor,HR)阳性早期乳腺癌预后最好,然而随着人类表皮生长因子受体2(human epidermal growth factor receptor 2,HER2)阳性乳腺癌抗HER2靶向治疗和三阴性乳腺癌强化治疗的发展,HR阳性早期乳腺癌预后优势已不再明显。当前,术后应用他莫昔芬或芳香化酶抑制单药进行内分泌治疗是HR阳性早期乳腺癌核心辅助治疗方式,但部分患者复发风险高、长期生存情况并不乐观。为改善患者预后、提高生活质量,目前临床主要探索方向包括以下三方面:① 强化治疗。强化方式包括延长内分泌治疗、联合卵巢功能抑制等,近期研究还探索了细胞周期蛋白依赖性激酶4/6抑制剂用于HR阳性早期乳腺癌患者强化治疗的效果和安全性。同时,如何有效地辨别适合于强化治疗的高危患者亦是研究热点,乳腺癌指数、STEPP分析等已获得权威指南推荐用于辅助强化治疗决策。② 化疗降阶/免化疗:精准化疗是目前国际主流趋势,多个国际指南推荐使用多基因检测工具如MammaPrint ® 、Oncotype DX ® 、EndoPredict ® 等分析结果辅助决策化疗降阶,以避免过度治疗。这些检测工具在我国患者中的临床研究和应用也日益增加,有望帮助提升我国患者获益。③ 术前内分泌治疗:尽管术前内分泌治疗可否给HR阳性早期乳腺癌患者带来直接获益尚待确认,但治疗过程中的生化指标变化与患者预后密切相关,或可在后续治疗决策(如是否可免除化疗、是否适用细胞周期蛋白依赖性激酶4/6抑制剂等)中发挥重要的指导作用,值得临床积极探索。本文将就上述HR阳性早期乳腺癌治疗的现状和研究进展进行综述和探讨,以期为临床医生提供参考。

关键词: 激素受体阳性乳腺癌, 内分泌治疗, 早期乳腺癌, 研究进展

Abstract: Early breast cancer can be cured if treated effectively upon diagnosis. Long-term disease-free survival should thus be the treatment goal for patients with early breast cancer. Hormone receptor (HR)-positive early breast cancer was believed to have the best prognosis among all the subtypes. However, as treatments for the human epidermal growth factor receptor 2 (HER2)- positive and triple-negative breast cancer advance, HR-positive breast cancer no longer exhibits an obvious prognostic advantage. At present, postoperative endocrine monotherapy with tamoxifen or aromatase inhibitors is the mainstay of adjuvant treatment for HR-positive early breast cancer. However, some patients are at a high risk of disease recurrence which would greatly affect their long-term survival. To improve the prognosis and quality of life for these patients, clinical research has been focusing on three main directions: ① Treatment escalation: patients at risk are recommended to escalate treatment by extending endocrine therapy or adding ovarian function suppression etc. Recent studies also explored the efficacy and safety of cyclin-dependent kinase 4 and 6 inhibitors as an option for treatment escalation in HR-positive early breast cancer. Accurate identification of high-risk patients suitable for treatment escalation is also a research hotspot where breast cancer index and STEPP analysis have already been recommended by authoritative guidelines to assist in the decision-making of treatment escalation. ② De-escalation or exemption of chemotherapy: to avoid excessive use of chemotherapy is a main trend in the area. Several international guidelines recommend using gene expression profiling tools such as MammaPrint ® , Oncotype DX ® and EndoPredict ® to help predict the necessity of adjuvant chemotherapy. The clinical research and use of these tools are also increasing in China and may help bring more benefits to Chinese patients. ③ Preoperative endocrine therapy: although the beneficial effect of preoperative endocrine therapy remains to be further investigated, a number of studies have suggested that changes in certain biomarkers during preoperative endocrine therapy are closely related to patient prognosis and may play an important role in subsequent treatment decisions (e.g., exemption of chemotherapy, application of cyclin-dependent kinase 4 and 6 inhibitors). This review summarized and discussed the above mentioned treatment landscape and recent research progress of HR-positive breast cancer, to provide reference for clinicians.

Key words: Hormone receptor-positive breast cancer, Endocrine therapy, Early breast cancer, Research progress