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江泽飞2011乳腺癌指南实践共识

'江泽飞2011乳腺癌指南实践共识'
2011 乳腺癌治疗 指南 实践 共识307医院乳腺肿瘤科 江泽飞 乳癌综合治疗进展? 外科手术的发展? 放疗地位和新思路? 晚期治疗 -- 内科医生的传统领地? 辅助治疗 -- 分类治疗策略 St.Gallen? 新辅助治疗 – 内外合作的平台 1950 肿瘤内科在乳腺癌的综合治疗中 开始发挥重要作用 化 疗 Radiotherapy Hormonal manipulation Surgery 3000 BC 1500’s 1800’s 1937 1950Rayter & Mansi. Medical Therapy of Breast Cancer 2003赫赛汀改变了HER2阳性转移性乳腺癌的进程 HER2 Negative ( n=1782 ) HER2+ No Herceptin ( n=118 ) HER2+ Herceptin ( n=191 ) Dawood S, et al. J Clin Oncol. 2010; 28:92-98.Her-2 阳性乳腺癌诊疗专家共识 (2009.08 上海)) 中国抗癌协会乳腺癌专业委员会 江泽飞 邵志敏 徐兵河等, 《中华肿瘤杂志》 2010;2 (32)Avastin in Her-2 Negative Metastatic Breast Cancer Current and Future 贝伐珠单抗治疗乳腺癌 痛苦地思考 如何用? 用不用??Avastin Regulatory History in US: 2010 / 07 FDA Recommends Removal of Bevacizumab's Breast Cancer Indication l The ODAC vote 12-1 that this indication be removed from bevacizumab’s label, reasons: – No overall survival advantage – High cost – Toxicity NCCN Recommendation Standsl Avastin plus Paclitaxel still be recommended as 1st line option in US http://www.ascopost.com/articles/january-15-2011/fda-recommends-removal- of-bevacizumab's-breast-cancer-indication/ 复发转移乳腺癌化疗基本原则 中国抗癌协会乳腺癌专业委员会一、复发转移乳腺癌的治疗前评估1、首先系统评估复发转移乳腺癌患者,明确病变 范围为局限性还是全身性疾病。2、尽可能对复发病灶活检,重新检测激素受体 (ER和PR) 和 HER-2状况。 3、确诊骨转移患者,治疗可参考《中国乳腺癌 骨转移和骨相关事件专家共识》。Questions in Chemotherapy for EBC 2011 Can we avoid chemotherapy? Which regimen is best? Can we avoid anthracyclines? Do we need a taxane? If yes, which one? If yes, concurrent vs sequential? What is the best HER2 regimen? How do we integrate biologics such as bevacizumab? 改变临床实践的 AI 临床试验结果 16 复 12 发 率/ 年 8 (%) 4 初始 转换 延续 0 (年) 0 2 3 5 8 10阿那曲唑 ATAC ABCSG 8, ARNO95, ITA ABCSG 6a 来曲唑 BIG 1-98 MA 17依西美坦 TEAM IES B 33 St. Gallen 2011 Strategies for Subtypes: Dealing with the Diversity of Breast Cancer Recommendations Consensus & Controversy St. Gallen Consensus Overview– Surgery: sentinel node– Radiation: DCIS, accelerated, partial, post mastectomy– Pathology: ER, PgR, HER2, Ki-67, grade– Multi-gene signatures– Endocrine therapies (focusing on ovarian suppression, tamoxifen, AIs)– Chemotherapy (focusing on anthracycline, taxane, platinum)– Targeted therapies– Neoadjuvant systemic therapy– Bisphosphonates– Male breast cancer Breast Cancer Subtypes 乳癌手术治疗发展? 1894年 乳癌根治术? 1949年 乳癌扩大根治术 乳癌改良根治术? 1973-77年 乳癌保乳手术? 1992年 保留腋窝的手术腋窝也可以不用清扫 前哨淋巴结活检术NSABP B-32 随机 III期临床研究 NSABP B-32 : 前哨淋巴结切除术 对比 腋窝淋巴结清扫术 用于临床表现为淋巴结阴性的 乳腺癌患者 2010 ASCO Abstract No:LBA505ACOSOG Z 0011 腋窝淋巴结清扫术 在 T1-2 N0 M0 期 前哨淋巴结阳性 乳腺癌的随机研究2010 ASCO No. CRA506 Neoadjuvant Systemic Therapy? Should neoadjuvant therapy be given only in order to alter the surgical outcome (less than mastectomy)? Yes: 37.2% No: 60.5% A: 2.3% Neoadjuvant Systemic Therapy? Is neoadjuvant endocrine therapy alone a reasonable option for postmenopausal pts. with highly endocrine-responsive disease? Yes: 97.8% No 2.2% A: 0.0% If yes, for which duration (choose one)? – 3-4 months Yes: 15.2% – 4-8 months Yes: 39.1% – Maximal response Yes: 45.7% Primary Consideration (agreed on by majority of participants)? Primary goal - treatment choice for women with early breast cancer: ? Integrate tumor biology and tumor extent into an estimate of responsiveness to treatment and risk of relapse ? Utilize tumor biology, host biology and risk to obtain an optimal management strategy ? Patient’s preference 2011 乳腺癌治疗 指南 实践 共识307医院乳腺肿瘤科 江泽飞 乳癌综合治疗进展? 外科手术的发展? 放疗地位和新思路? 晚期治疗 -- 内科医生的传统领地? 辅助治疗 -- 分类治疗策略 St.Gallen? 新辅助治疗 – 内外合作的平台 1950 肿瘤内科在乳腺癌的综合治疗中 开始发挥重要作用 化 疗 Radiotherapy Hormonal manipulation Surgery 3000 BC 1500’s 1800’s 1937 1950Rayter & Mansi. Medical Therapy of Breast Cancer 2003赫赛汀改变了HER2阳性转移性乳腺癌的进程 HER2 Negative ( n=1782 ) HER2+ No Herceptin ( n=118 ) HER2+ Herceptin ( n=191 ) Dawood S, et al. J Clin Oncol. 2010; 28:92-98.Her-2 阳性乳腺癌诊疗专家共识 (2009.08 上海)) 中国抗癌协会乳腺癌专业委员会 江泽飞 邵志敏 徐兵河等, 《中华肿瘤杂志》 2010;2 (32)Avastin in Her-2 Negative Metastatic Breast Cancer Current and Future 贝伐珠单抗治疗乳腺癌 痛苦地思考 如何用? 用不用??Avastin Regulatory History in US: 2010 / 07 FDA Recommends Removal of Bevacizumab's Breast Cancer Indication l The ODAC vote 12-1 that this indication be removed from bevacizumab’s label, reasons: – No overall survival advantage – High cost – Toxicity NCCN Recommendation Standsl Avastin plus Paclitaxel still be recommended as 1st line option in US http://www.ascopost.com/articles/january-15-2011/fda-recommends-removal- of-bevacizumab's-breast-cancer-indication/ 复发转移乳腺癌化疗基本原则 中国抗癌协会乳腺癌专业委员会一、复发转移乳腺癌的治疗前评估1、首先系统评估复发转移乳腺癌患者,明确病变 范围为局限性还是全身性疾病。2、尽可能对复发病灶活检,重新检测激素受体 (ER和PR) 和 HER-2状况。 3、确诊骨转移患者,治疗可参考《中国乳腺癌 骨转移和骨相关事件专家共识》。Questions in Chemotherapy for EBC 2011 Can we avoid chemotherapy? Which regimen is best? Can we avoid anthracyclines? Do we need a taxane? If yes, which one? If yes, concurrent vs sequential? What is the best HER2 regimen? How do we integrate biologics such as bevacizumab? 改变临床实践的 AI 临床试验结果 16 复 12 发 率/ 年 8 (%) 4 初始 转换 延续 0 (年) 0 2 3 5 8 10阿那曲唑 ATAC ABCSG 8, ARNO95, ITA ABCSG 6a 来曲唑 BIG 1-98 MA 17依西美坦 TEAM IES B 33 St. Gallen 2011 Strategies for Subtypes: Dealing with the Diversity of Breast Cancer Recommendations Consensus & Controversy St. Gallen Consensus Overview– Surgery: sentinel node– Radiation: DCIS, accelerated, partial, post mastectomy– Pathology: ER, PgR, HER2, Ki-67, grade– Multi-gene signatures– Endocrine therapies (focusing on ovarian suppression, tamoxifen, AIs)– Chemotherapy (focusing on anthracycline, taxane, platinum)– Targeted therapies– Neoadjuvant systemic therapy– Bisphosphonates– Male breast cancer Breast Cancer Subtypes 乳癌手术治疗发展? 1894年 乳癌根治术? 1949年 乳癌扩大根治术 乳癌改良根治术? 1973-77年 乳癌保乳手术? 1992年 保留腋窝的手术腋窝也可以不用清扫 前哨淋巴结活检术NSABP B-32 随机 III期临床研究 NSABP B-32 : 前哨淋巴结切除术 对比 腋窝淋巴结清扫术 用于临床表现为淋巴结阴性的 乳腺癌患者 2010 ASCO Abstract No:LBA505ACOSOG Z 0011 腋窝淋巴结清扫术 在 T1-2 N0 M0 期 前哨淋巴结阳性 乳腺癌的随机研究2010 ASCO No. CRA506 Neoadjuvant Systemic Therapy? Should neoadjuvant therapy be given only in order to alter the surgical outcome (less than mastectomy)? Yes: 37.2% No: 60.5% A: 2.3% Neoadjuvant Systemic Therapy? Is neoadjuvant endocrine therapy alone a reasonable option for postmenopausal pts. with highly endocrine-responsive disease? Yes: 97.8% No 2.2% A: 0.0% If yes, for which duration (choose one)? – 3-4 months Yes: 15.2% – 4-8 months Yes: 39.1% – Maximal response Yes: 45.7% Primary Consideration (agreed on by majority of participants)? Primary goal - treatment choice for women with early breast cancer: ? Integrate tumor biology and tumor extent into an estimate of responsiveness to treatment and risk of relapse ? Utilize tumor biology, host biology and risk to obtain an optimal management strategy ? Patient’s preference 2011 乳腺癌治疗 指南 实践 共识307医院乳腺肿瘤科 江泽飞 乳癌综合治疗进展? 外科手术的发展? 放疗地位和新思路? 晚期治疗 -- 内科医生的传统领地? 辅助治疗 -- 分类治疗策略 St.Gallen? 新辅助治疗 – 内外合作的平台 1950 肿瘤内科在乳腺癌的综合治疗中 开始发挥重要作用 化 疗 Radiotherapy Hormonal manipulation Surgery 3000 BC 1500’s 1800’s 1937 1950Rayter & Mansi. Medical Therapy of Breast Cancer 2003赫赛汀改变了HER2阳性转移性乳腺癌的进程 HER2 Negative ( n=1782 ) HER2+ No Herceptin ( n=118 ) HER2+ Herceptin ( n=191 ) Dawood S, et al. J Clin Oncol. 2010; 28:92-98.Her-2 阳性乳腺癌诊疗专家共识 (2009.08 上海)) 中国抗癌协会乳腺癌专业委员会 江泽飞 邵志敏 徐兵河等, 《中华肿瘤杂志》 2010;2 (32)Avastin in Her-2 Negative Metastatic Breast Cancer Current and Future 贝伐珠单抗治疗乳腺癌 痛苦地思考 如何用? 用不用??Avastin Regulatory History in US: 2010 / 07 FDA Recommends Removal of Bevacizumab's Breast Cancer Indication l The ODAC vote 12-1 that this indication be removed from bevacizumab’s label, reasons: – No overall survival advantage – High cost – Toxicity NCCN Recommendation Standsl Avastin plus Paclitaxel still be recommended as 1st line option in US http://www.ascopost.com/articles/january-15-2011/fda-recommends-removal- of-bevacizumab's-breast-cancer-indication/ 复发转移乳腺癌化疗基本原则 中国抗癌协会乳腺癌专业委员会一、复发转移乳腺癌的治疗前评估1、首先系统评估复发转移乳腺癌患者,明确病变 范围为局限性还是全身性疾病。2、尽可能对复发病灶活检,重新检测激素受体 (ER和PR) 和 HER-2状况。 3、确诊骨转移患者,治疗可参考《中国乳腺癌 骨转移和骨相关事件专家共识》。Questions in Chemotherapy for EBC 2011 Can we avoid chemotherapy? Which regimen is best? Can we avoid anthracyclines? Do we need a taxane? If yes, which one? If yes, concurrent vs sequential? What is the best HER2 regimen? How do we integrate biologics such as bevacizumab? 改变临床实践的 AI 临床试验结果 16 复 12 发 率/ 年 8 (%) 4 初始 转换 延续 0 (年) 0 2 3 5 8 10阿那曲唑 ATAC ABCSG 8, ARNO95, ITA ABCSG 6a 来曲唑 BIG 1-98 MA 17依西美坦 TEAM IES B 33 St. Gallen 2011 Strategies for Subtypes: Dealing with the Diversity of Breast Cancer Recommendations Consensus & Controversy St. Gallen Consensus Overview– Surgery: sentinel node– Radiation: DCIS, accelerated, partial, post mastectomy– Pathology: ER, PgR, HER2, Ki-67, grade– Multi-gene signatures– Endocrine therapies (focusing on ovarian suppression, tamoxifen, AIs)– Chemotherapy (focusing on anthracycline, taxane, platinum)– Targeted therapies– Neoadjuvant systemic therapy– Bisphosphonates– Male breast cancer Breast Cancer Subtypes 乳癌手术治疗发展? 1894年 乳癌根治术? 1949年 乳癌扩大根治术 乳癌改良根治术? 1973-77年 乳癌保乳手术? 1992年 保留腋窝的手术腋窝也可以不用清扫 前哨淋巴结活检术NSABP B-32 随机 III期临床研究 NSABP B-32 : 前哨淋巴结切除术 对比 腋窝淋巴结清扫术 用于临床表现为淋巴结阴性的 乳腺癌患者 2010 ASCO Abstract No:LBA505ACOSOG Z 0011 腋窝淋巴结清扫术 在 T1-2 N0 M0 期 前哨淋巴结阳性 乳腺癌的随机研究2010 ASCO No. CRA506 Neoadjuvant Systemic Therapy? Should neoadjuvant therapy be given only in order to alter the surgical outcome (less than mastectomy)? Yes: 37.2% No: 60.5% A: 2.3% Neoadjuvant Systemic Therapy? Is neoadjuvant endocrine therapy alone a reasonable option for postmenopausal pts. with highly endocrine-responsive disease? Yes: 97.8% No 2.2% A: 0.0% If yes, for which duration (choose one)? – 3-4 months Yes: 15.2% – 4-8 months Yes: 39.1% – Maximal response Yes: 45.7% Primary Consideration (agreed on by majority of participants)? Primary goal - treatment choice for women with early breast cancer: ? Integrate tumor biology and tumor extent into an estimate of responsiveness to treatment and risk of relapse ? Utilize tumor biology, host biology and risk to obtain an optimal management strategy ? Patient’s preference 2011 乳腺癌治疗 指南 实践 共识307医院乳腺肿瘤科 江泽飞 乳癌综合治疗进展? 外科手术的发展? 放疗地位和新思路? 晚期治疗 -- 内科医生的传统领地? 辅助治疗 -- 分类治疗策略 St.Gallen? 新辅助治疗 – 内外合作的平台 1950 肿瘤内科在乳腺癌的综合治疗中 开始发挥重要作用 化 疗 Radiotherapy Hormonal manipulation Surgery 3000 BC 1500’s 1800’s 1937 1950Rayter & Mansi. Medical Therapy of Breast Cancer 2003赫赛汀改变了HER2阳性转移性乳腺癌的进程 HER2 Negative ( n=1782 ) HER2+ No Herceptin ( n=118 ) HER2+ Herceptin ( n=191 ) Dawood S, et al. J Clin Oncol. 2010; 28:92-98.Her-2 阳性乳腺癌诊疗专家共识 (2009.08 上海)) 中国
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