Early healing: Exploration of HR+Early Breast Cancer Endocrine Treatment Optimization Strategy

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GLOBOCAN 2020 database [1] shows that female breast cancer surpasses lung cancer for the first time to become the world's most common cancer. In 2020, 2,261,419 new breast cancer was 2,261,419, accounting for 11.7%of the overall cancer. In China, breast cancer has become the largest malignant tumor that threatens women's health, and the incidence is increasing year by year.

治愈是早期乳腺癌治疗的终极目标，最初，乳腺癌治愈的信心来自于激素受体阳性（HR+）乳腺癌，随着新型治疗药物的出现，HER2+和三阴性乳腺癌（TNBC）早期患者生存预后Continuous improvement, the prognosis of HR+/HER2-early breast cancer no longer exists. So, how should HR+/HER2-early breast cancer optimize the auxiliary treatment strategies to achieve the ultimate goal of cure?

Strengthening and extending is the main method of endocrine "upgrade ladder" treatment

In HR+early breast cancer, 5 years of auxiliary endocrine therapy can significantly reduce the risk of local and distant recurrence, opposite breast cancer and breast cancer death. Moqifen's disease -free survival (DFS) does not exceed 85%, which means that there are still some high -risk HR+early breast cancer patients urgently need endocrine "upgrade ladder" treatment.

There are two main modes of endocrine "upgrade ladder" treatment. One is to strengthen the use of other drugs on the basis of standard -assisted therapy, and the other is to extend the treatment time. "Guidelines and Specifications for Breast Cancer Diagnosis and Treatment of the China Anti -Cancer Association (2021 Edition)" Recommended pre -menopausal patients to assist endocrine therapy schemes: he Moqifen, ovarian function suppression (OFS)+him Moqifen, OFS+third generation of the third generation Castase inhibitors (AI), such as non -steroidal cateramrazole and cymbal category Esican. The OFS method has drugs, surgical resection ovaries, and ovarian radiation irradiation. Because the commonly used OFS drugs are GNRH agonists (GNRHA) such as Gosherin and Line Bingrein, they can quickly reduce the level of female serum estrogen and reach postmenopausal state. This effect is reversed after stopping the drug. Because the GNRH agonist has now entered medical insurance, considering the creativeness and irreversibility of surgery, and limited radiotherapy effect, "Early breast cancer ovarian function inhibit the clinical application expert consensus (2021)" [5] It is recommended to remove the drug GNRHA is the preferred recommendation of early breast cancer OFS as pre -menopamental hormone receptor. If a drug -based OFS is used, the general recommended treatment time is 5 years.

OFS drugs are recommended for patients with high recurrence risks. Specific considering considering age, lump size, lymph node status, organizational grading, Ki-67 proliferation index, etc., can also be evaluated by Stepp. "China Clinical Oncology Society (CSCO) Breast Cancer Diagnosis and Treatment Guide (2022 Edition)" [3] For pre -menopausal patients to assist endocrine therapy strategies as follows: If armpit lymph nodes are ≥ 4 positives, level I recommend OFS+AI 5 5 In 2 years ± Abercille, Class II recommended OFS+TAM 5 years ± Abityli for 2 years; if the armpit lymph nodes are 1 ~ 3 positive and have the following risk factors: T ≥5cm, G3, Ki-67 ≥2020 %, Grade Ⅰ Recommended OFS+TAM 5 years ± Abityli 2 years, Class II recommended OFS+AI 5 years ± Abesili for 2 years; One of the following risk factors: G2 or G3, T & 2CM, high Ki-67 index, level I recommend OFS+TAM 5 years, level Ⅱ recommendation of OFS+AI 5 years; , Low Ki-67 Index, level I recommend TAM for 5 years. In subsequent intensive treatment, if OFS+AI has been treated in 5 years and has good tolerance, patients with unparalleled menstruation can consider using TAM 5 years or OFS+AI 5 years.

"China Clinical Oncology Society (CSCO) Breast Cancer Diagnosis and Treatment Guide (2022 Edition)" [3] The AI ​​5 -year+Abestri 2 -year treatment plan (1A evidence) is used as a patient with high recurrence risk after menopause. Grade Ⅰ treatment recommendation, TAM 5 years+Abelley's 2 -year treatment plan (1A evidence) is recommended as class II treatment.

Multi -gene tools help chemotherapy "staircase" treatment

While endocrine therapy "upgrade ladder" treatment, chemotherapy "ladder reduction" has also become a treatment trend. It can be used to apply multi -gene detection tools including 21 gene testing and 70 gene detection patients. Starting from clinical and pathological characteristics, including tumor size, tissue grading, lymph node metastasis, pathological types, immunohistochemical types, and expression conditions such as Ki-67, ER, PR, and HER2 Based on, multi -gene testing can help clinicians more accurately evaluate the risk of recurrence of patients, further improve the level of clinical decision -making, balance the efficacy and side effects brought by the auxiliary therapy, and then improve the "net benefit" of treatment.

"Guidelines for the Diagnosis and Treatment of Breast Cancer Cancer in the United States Cancer Comprehensive Network (NCCN)" [4] pointed out that 21 gene test results have T1B/C-2, PN0, HR+, HER2-tumor, risk score (RS) between 0-10 The risk of recurrence in the distance <4%, while the postmenopausal patients of RS 11-25 have no benefit of chemotherapy on the basis of endocrine therapy. For postmenopausal patients with PT1-3, PN1, HR+, HER2-, and RS <26, chemotherapy has not benefited from chemotherapy on the basis of endocrine therapy. For postmenopausal patients with PT1-3, HR+, HER2-, PN0, and PN1 (1-3 positive lymph nodes) and RS ≥ 26, chemotherapy is recommended to use the end secretion therapy. For patients before menopause, T1B/C-2, PN0, HR+, HER2-Tumor and RS <16 are not benefited from chemotherapy on the basis of endocrine therapy. For pre-menopausal patients with RS values ​​between 16-25, a small amount of benefits of adding chemotherapy cannot be ruled out, but it is not clear whether this benefit is caused by the ovarian inhibitory effect caused by patients receiving chemotherapy before menopause. For this group of patients, chemotherapy sequences can be used for endocrine therapy, or the combination of OFS and TAM or AI can be considered. For pre-menopausal patients with HR+, HER2-, PN0 tumors and RS ≥ 26, chemotherapy is recommended to use endocrine therapy.

Among patients with PT1-3 and PN1 (1-3 positive lymph nodes) tumors and RS <26 pre-menopause patients, compared with endocrine single drug treatment, chemotherapy and lower distant recurrence on the basis of endocrine treatment are used It is related, but it is unclear whether this benefit is caused by the ovarian inhibitory effect promoted by chemotherapy. For the group of patients, consider the sequence of endocrine therapy after chemotherapy, or consider combining OFS with him or AI. "Early breast cancer ovarian function inhibits clinical application expert consensus (2021)" [5] states that patients with low -risk selection of OFS for chemotherapy can consider OFS combined with endocrine therapy for 2 years. For pre-menopausal patients with HR+, HER2-, PT1-3, and PN1 (1-3 positive lymph nodes) and RS ≥ 26, chemotherapy is recommended to be used on the basis of endocrine therapy.

Summarize

In order to achieve the ultimate goal of HR+early breast cancer cure, patients should be layered and more individualized. At present, endocrine "lift stairs" and chemotherapy "staircase" treatment model is a decision -making trend in clinical practice. High -risk early patients have an important position in OFS and CDK4/6 inhibitors and obtain authoritative guidelines. Early patients with low -risk patients blindly blindly blindly. Accepting chemotherapy does not bring additional benefits. It is necessary to rely on gene expression analysis and guidance to assist therapeutic decisions. For some patients, some patients can choose OFS to replace chemotherapy. It is believed that with the further enrichment of evidence of evidence -based medicine, the auxiliary treatment decision -making decisions of HR+early breast cancer patients can also be optimized.

Expert Introduction

Cheng Lin

Associate Professor of Chief Physician

Ph.D.

Deputy Director of the Surgery and Research Office of Peking University People's Hospital

Standing Committee of the Breast Cancer Professional Committee of Chinese Cancer Society

Member of the Surgeon Special Committee of the Chinese Physician Association Surgeon Branch

Standing Committee Member of the Chinese Research Hospital Society of Breast Diseases

Deputy Chairman of the Youth Committee of the Chinese Research Hospital Society

Standing Committee Member of the Beijing Breast Disease Prevention Society Transformation Medical Professional Committee

Standing Committee Member of the Beijing Breast Disease Prevention Society Prevention and Health Care Commission

Standing Committee Member of the Breast Disease Branch of China Medical Care International Exchange Promotion Association

Member of the Surgery Professional Committee of Beijing Breast Disease Prevention and Control Society

Member of the Academic Professional Committee of Beijing Breast Disease Prevention and Control Society

Member of the Beijing Medical Association's Breast Disease Professional Committee

references:

[1] Cao Mao Mao, Chen Wanqing. GLOBOCAN 2020 Global Cancer Statistics Interpretation [J]. Chinese Medical Frontier Magazine (electronic version), 2021, 13 (3): 63-69

[2] The Breast Cancer Professional Committee of the China Anti-Cancer Association. The Guidelines and Specifications of Breast Cancer Diagnosis and Treatment of the China Anti-Cancer Association (2021) [J]. China Cancer Magazine, 2021, 31 (10): 954-1040.

[3] "Chinese Clinical Oncology Society of Breast Cancer (CSCO BC) Diagnosis and Treatment Guide (2022)". 2022.

[4] NCCN Clinical Practice Guidelines in OnCology (NCCN Guidelines®). Breast Cancer, Version 4.2022.

[5] The Breast Cancer Professional Committee of the China Anti-Cancer Association. China ’s early breast cancer ovarian function inhibiting clinical application expert consensus (2021 edition) [J]. China Cancer Magazine, 2022, 32 (2): 177-190.

Disclaimer: This article is supported by Astraikon for reference for medical and health professionals.

Approval number: CN-102173

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