First, the situation should be based on hormone receptor to choose whether to endocrine therapy. Estrogen (ER) and / or progesterone (PR) receptor-positive patients, especially estrogen receptor-positive patients, postoperative adjuvant chemotherapy as a sequential therapy or individual therapy can significantly improve the 10-year disease-free breast cancer patients survival (DFS) and overall survival (OS). 2008 U.S. National Comprehensive Cancer Network (NCCN) treatment guidelines recommended that, for common histological types of early breast cancer patients, need to make sure that all primary invasive breast cancer, estrogen receptor (ER) and progesterone receptor (PR) status. Where the ER or PR-positive invasive breast cancer patients, regardless of age, lymph node status, or whether it applied to adjuvant chemotherapy, adjuvant endocrine therapy should be considered, but those with negative lymph nodes and patients who meet the following conditions except: 1. Primary tumor micro-invasion, 2. lesion diameter less than 0.5cm, 3. lesion diameter 0.6-1.0cm, well-differentiated and no adverse prognostic factor, because a good prognosis of these patients, the benefit from endocrine therapy is very limited.
Second, to determine whether post-menopausal breast cancer, endocrine therapy is to choose the type of foundation. Of breast cancer adjuvant endocrine therapy need to first determine whether the menopause. Need to use pre-menopausal tamoxifen and aromatase inhibitors in postmenopausal patients with more effective than tamoxifen in postmenopausal preferred aromatase inhibitors. Because aromatase inhibitors on ovarian function in patients with no effect, it is not used for pre-menopausal. The current definition of menopause are: 1, bilateral ovarian resection; 2, older than 60 years of age; 3, younger than 60 years of age, menopause more than 12 months, did not accept chemotherapy, tamoxifen, care Rui Mifen or receive ovarian function suppression therapy, and the FSH and estradiol levels in postmenopausal women ranges; 4, younger than 60 years old, are taking tamoxifen or toremifene, FSH and estradiol level should be In the context of post-menopausal; 5, are receiving LH-RH agonist or inhibitor treatment of patients are unable to determine whether the post-menopausal; 6, is undergoing chemotherapy, pre-menopausal women, menopause can not serve as a basis to judge post-menopausal; 7, because, although patients In an interview after chemotherapy appears to stop ovulation or menopause, ovarian function, but may still be possible to resume a normal or. For chemotherapy-induced menopause in women, considering the aromatase inhibitors as endocrine therapy, it would take to remove or continuous repeated detection of ovarian FSH and / or estradiol levels to ensure that the patient remains in menopausal status.
(1) postmenopausal hormone receptor-positive patients, adjuvant endocrine therapy may choose to:
1. Anastrozole or letrozole for 5 years;
2. Tamoxifen after 2-3 years, 2-3 years of sequential use of exemestane or anastrozole;
3. Tamoxifen 5 years later, the follow-up to strengthen the use of letrozole or exemestane for 5 years;
4. For there is an aromatase inhibitor in patients with contraindications or can not accept the aromatase inhibitor, or can not tolerate an aromatase inhibitor, you can still use tamoxifen for 5 years.
(2) pre-menopausal patients with hormone receptor-positive adjuvant endocrine therapy may choose to:
1. Tamoxifen for 5 years;
2. The first 2-3 years with tamoxifen, such as entering menopause, you can switch to an aromatase inhibitor after 5 years.
3. If you did not even after 2-3 years of tamoxifen menopause, can continue to use tamoxifen to 5 years, such as five years later, after menopause, further follow-up to strengthen the aromatase inhibitor for 5 years.
4. For some not suitable for treatment with tamoxifen, or have high risk factors of recurrence and metastasis pre-menopausal patients, can be considered in the effective inhibition of ovarian function, taking into account the principle of post-menopausal women, choose to use aromatase inhibitors as adjuvant therapy.
China’s relatively high pre-menopausal breast cancer and its treatment specificity. Treatment of ovarian function suppression already successful experience in pre-menopausal breast cancer, ovarian function suppression may be surgery or drug suppression (Zoladex Zoladex), drug suppression to overcome the shortcomings of castration surgery and radiotherapy, and the function of reversible better for young patients acceptance.
(3) adjuvant endocrine therapy for the views of a number of issues
Adjuvant endocrine therapy for more than 30 years of history, but clinical applications, there are still a lot of confusion on the current literature and expert opinions, and adjuvant endocrine therapy for the views of a number of issues:
1. Although some of the sub-group analysis of clinical research results indicate that, ER-positive patients with PR status, Her-2 expression in patients with hormonal therapy may affect the results, but because some of the results in itself contradictory, but are not the results of prospective randomized controlled study Therefore, patients with ER-positive PR status, Her-2 expression would not affect the effectiveness of endocrine therapy is currently no clear conclusion.
2. Tamoxifen remains the treatment of the role and status of 5-year follow-up 15 years after treatment can decrease the risk of death;
3. Aromatase inhibitors in postmenopausal patients with more effective than tamoxifen, to determine its efficacy, safety and reliability. The long-term drug use has increased osteoporosis, high blood lipids, the risk of cardiovascular adverse events, but not serious.
4. Aromatase inhibitor efficacy between the different usage of the ongoing comparative study, the best drug treatment has not been established. Therefore, the relatively low-risk patients, especially perimenopausal period and pre-menopausal patients, can first 2-3 years of tamoxifen, even after 4-5 years, consider switching to an aromatase inhibitor.
5. Aromatase inhibitors in different clinical studies between the results showed that the difference between the efficacy and safety, provide an important further research information, but basically does not change the clinical treatment decision-making.
6. NCCN-defined criteria for determining menopause, although sometimes because of clinical factors such as chemotherapy, will face can not accurately determine whether specific issues such as menopause. It should be noted that the standard itself is summarized previous clinical research experience, ensuring that patients only be used after menopause, aromatase inhibitors, so those who are unable to determine post-menopausal patients, can not use aromatase inhibitors, only the use of tamoxifen, or in Effective suppression of ovarian function after an aromatase inhibitor or tamoxifen.
7. The international community is currently premenopausal and perimenopausal patients with adjuvant endocrine therapy for conclusive results much. So, in the absence of established post-menopausal and without the adoption of effective, when ovarian function suppression, tamoxifen is still essential drugs. Some high-risk premenopausal patients with recurrence and metastasis (eg, primary tumor> 5cm, LNM> 3, Her-2 overexpression, etc.), may consider surgery or drugs in an effective inhibition of ovarian function, taking into account the principle of post-menopausal women, the use of aromatic enzyme inhibitors. But the need to be reminded that there is no clear evidence-based medical evidence that ovarian function to discourage the use of aromatase inhibitors, the efficacy advantage, but also the results of clinical studies to be at home and abroad to give evidence.
