Strategies for classification of advanced breast cancer

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MBC profiles and treatment principles for metastatic breast cancer are incurable disease, but some patients can survive longer and have a be


MBC profiles and treatment principles for metastatic breast cancer are incurable disease, but some patients can survive longer and have a better quality of life. The treatment of breast cancer has entered the era of molecular classification, according to the hormone receptor, HER2 expression and immunohistochemical results of breast cancer can be roughly divided into four categories, should be selected for different subtypes of the most appropriate treatment options. MBC treatment options in addition to the biological characteristics of the tumor, but also consider the patient factors (age, physical condition, following to the disease and economic conditions), factors of postoperative adjuvant therapy (drug, dose, time) and patient preference. At present, the MBC clinical decision should respect the patient's own choice.

MBC total treatment strategy for patients with ER positive /HER2 negative advanced breast cancer, there are two main ways of chemotherapy and endocrine therapy. How to weigh? Is the choice of chemotherapy, or endocrine therapy? Domestic tradition is more of a choice of chemotherapy, but according to some of the current international guidelines, endocrine therapy should be more attention. Expert consensus on advanced breast cancer (ESO-ESMO 2nd international consensus ABC2 international guidelines for advanced breast cancer) recommended, endocrine therapy is the preferred ER+ for advanced breast cancer, unless there is need to quickly relieve diseases or endocrine resistance. ER+/HER- treatment of advanced breast cancer: the preferred first-line treatment principle of endocrine therapy, especially localized lesions of the breast, bone and soft tissue and no symptoms, the tumor load small visceral metastases to the endocrine treatment of sensitive patients, not only can delay the time to start chemotherapy patients, so that patients can maintain the quality of life and the good but for endocrine therapy resistance, tumor progression, metastasis or rapid visceral symptoms, need to quickly reduce the tumor load of patients should be given chemotherapy more effective in treatment and drug choice for secretion of endocrine therapy for premenopausal patients preferred choice, ovarian suppression or ovariectomy, combined with endocrine drugs (choice according to postmenopausal women). Postmenopausal patients is the preferred first-line endocrine drug tamoxifen or aromatase inhibitors, fulvestrant (500mg, every 4 weeks), medication and treatment depends on the duration of adjuvant therapy for stage. By comparison of several first-line endocrine drug efficacy in head to head, drug selection may have fulvestrant or aromatase inhibitors on the order of 500, tamoxifen. For first-line endocrine therapy is effective, some patients in the course of treatment failure, can be sequential to second-line treatment. However, from a number of clinical studies, the treatment of MBC (TPP) was only about 3-5 months, no more than half a year after the treatment of simple sequential dressing change. In recent years, to overcome the drug selection scheme of endocrine resistance develops rapidly, mainly including fulvestrant 500, exemestane + CDK4/6 + inhibitor everolimus, endocrine drugs etc.. That the second-line endocrine therapy clinical trials, either for PFS or OS, fulvestrant dose of 500mg is better than 250mg dose, exemestane + better than everolimus exemestane, fulvestrant 500mg+CDK4/6 inhibitor is better than that of fulvestrant 500mg. In the first line after the failure of the endocrine drugs on the choice of the above several programs on the effect of disease control may be better. "Three Yin" MBC chemotherapy is currently the most advanced in the treatment of breast cancer, and the application value of platinum drugs is the focus of attention in the treatment of three negative advanced breast cancer. A phase III randomized clinical study comparing carboplatin or docetaxel in the treatment of advanced TNT or BRCA1/2 mutation type three negative breast cancer. For the conventional three negative breast cancer patients, first-line treatment option of carboplatin docetaxel monotherapy or similar objective remission rate. For patients with BRCA1/2 mutations, objective and effective rate of carboplatin can reach 68%, but better than docetaxel, carboplatin can obviously prolong the patient's progression free survival. For patients without BRCA1/2 mutations, carboplatin and did not show superiority. From this study we can draw the following conclusions: in unselected patients with TNBC, treatment with docetaxel carboplatin; for patients with BRCA1/2 mutations, PFS and carboplatin in the treatment of remission rate was significantly higher than that of docetaxel; TNT research support for metastatic TNBC and familial breast cancer patients should be BRCA1/2 gene analysis to guide treatment selection. Two other clinical studies in China also showed that mTNB treatment with cisplatin in the first-line treatment of two drugs can improve ORR, extend PFS. Therefore, for patients with good tolerance, platinum containing programs can also be considered. ABC3 consensus that, for non BRCA related TNBC, there is no data to support targeted specific chemotherapy regimens, and therefore suitable for HER2 negative advanced breast cancer programs are applicable to TNBC. Negative for three patients with advanced breast cancer received neoadjuvant or adjuvant paclitaxel and anthracycline therapy (regardless of the BRCA status), carboplatin and docetaxel have similar efficacy and safety, can be treated as three negative advanced breast cancer of. The treatment of HER2 positive advanced breast cancer in the treatment of HER2 positive advanced breast cancer is based on HER2 targeted therapy. If HER2 and ER double positive, can be combined with endocrine therapy. Individualized drug or chemotherapy options may refer to the results of clinical trials (guidelines recommended). HER2 positive advanced breast cancer treatment strategies 2016NCCN V1 guidelines: the first-line therapy: pertuzumab plus trastuzumab plus taxane - second-line therapy: treatment other than TDM1, the second line: lapatinib / trastuzumab plus capecitabine / other chemotherapy, trastuzumab, imatinib + Rapa (dual targeting), trastuzumab / lapatinib plus aromatase inhibitors, everolimus plus trastuzumab vinorelbine + Changchun (alternative) because of pertuzumab and TDM1 has not yet been approved, so the domestic clinical practice commonly used first-line treatment of trastuzumab in combination with paclitaxel. For the treatment of HER2 positive advanced breast cancer, chemotherapy plus anti HER2 targeted therapy should be continued for 4-6 months or longer (to progress), and the need to balance toxicity. Chemotherapy is recommended to continue to target maintenance therapy. If ER/PR+, follow-up treatment is recommended as a target + endocrine therapy.

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