Shenkier Tamara, Weir Lorna, Levine Mark, Olivotto Ivo, Whelan Timothy, Reyno Leonard
BC Cancer Agency-Vancouver Cancer Centre, Vancouver, BC.
CMAJ. 2004 Mar 16;170(6):983-94. doi: 10.1503/cmaj.1030944.
To define the optimal treatment for women with stage III or locally advanced breast cancer (LABC).
Systematic review of English-language literature retrieved from MEDLINE (1984 to June 2002) and CANCERLIT (1983 to June 2002). A nonsystematic review of the literature was continued through December 2003.
The management of LABC requires a combined modality treatment approach involving surgery, radiotherapy and systemic therapy. Systemic therapy: chemotherapy. Operable tumours. Patients with operable stage IIIA disease should be offered chemotherapy. They should receive adjuvant chemotherapy following surgery, or primary chemotherapy followed by locoregional management. Chemotherapy should contain an anthracycline. Acceptable regimens are 6 cycles of FAC, CAF, CEF or FEC. Taxanes are under intense investigation. Inoperable tumours. Patients with stage IIIB or IIIC disease, including those with inflammatory breast cancer and those with isolated ipsilateral internal mammary or supraclavicular lymph-node involvement, should be treated with primary anthracycline-based chemotherapy. Acceptable chemotherapy regimens are FAC, CAF, CEF or FEC. Taxanes are under intense investigation. Patients with stage IIIB or IIIC disease who respond to primary chemotherapy should be treated until the response plateaus or to a maximum of 6 cycles (minimum 4 cycles). Patients with stage IIIB disease should then undergo definitive surgery and irradiation. The locoregional management of patients with stage IIIC disease who respond to chemotherapy should be individualized. In patients with stage IIIB or IIIC disease who achieve maximum response with fewer than 6 cycles, further adjuvant chemotherapy can be given following surgery and irradiation. Patients whose tumours do not respond to primary chemotherapy can be treated with taxane chemotherapy or can proceed directly to irradiation followed by modified radical mastectomy, if feasible. Systemic therapy: hormonal therapy. Operable and inoperable tumours. Tamoxifen for 5 years should be recommended to pre- and postmenopausal women whose tumours are hormone responsive. Locoregional management. Operable tumours. Patients with stage IIIA disease should receive both modified radical mastectomy (MRM) and locoregional radiotherapy if feasible. They may be managed with MRM followed by chemotherapy and locoregional radiotherapy, or chemotherapy first followed by MRM and locoregional radiotherapy. Breast-conserving surgery is currently not a standard approach. Locoregional radiotherapy should be delivered to the chest wall and to the supraclavicular and axillary nodes. The role of internal mammary irradiation is unclear. Inoperable tumours. Patients with stage IIIB disease who respond to chemotherapy should receive surgery plus locoregional radiotherapy. The locoregional management of patients with stage IIIC disease who respond to chemotherapy is unclear and should be individualized. Patients whose disease remains inoperable following chemotherapy should receive locoregional radiotherapy with subsequent surgery, if feasible.
The authors' original text was revised by members of the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Subsequently, feedback was provided by 9 oncologists from across Canada. The final document was approved by the steering committee.
The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. Completion date: December 2003.
确定III期或局部晚期乳腺癌（LABC）女性的最佳治疗方案。
对从MEDLINE（1984年至2002年6月）和CANCERLIT（1983年至2002年6月）检索到的英文文献进行系统综述。截至2003年12月持续进行非系统文献综述。
LABC的治疗需要综合治疗方法，包括手术、放疗和全身治疗。全身治疗：化疗。可手术肿瘤。对于可手术的IIIA期疾病患者，应给予化疗。他们应在手术后接受辅助化疗，或先进行新辅助化疗，然后进行局部区域治疗。化疗应包含蒽环类药物。可接受的方案为6周期的FAC、CAF、CEF或FEC。紫杉烷类正在进行深入研究。不可手术肿瘤。IIIB期或IIIC期疾病患者，包括炎性乳腺癌患者以及孤立的同侧内乳或锁骨上淋巴结受累患者，应接受以蒽环类药物为基础的新辅助化疗。可接受的化疗方案为FAC、CAF、CEF或FEC。紫杉烷类正在进行深入研究。对新辅助化疗有反应的IIIB期或IIIC期疾病患者应持续治疗至反应平台期或最多6周期（至少4周期）。然后，IIIB期疾病患者应接受确定性手术和放疗。对化疗有反应的IIIC期疾病患者的局部区域治疗应个体化。对于在少于6周期时达到最大反应的IIIB期或IIIC期疾病患者，可在手术和放疗后给予进一步的辅助化疗。肿瘤对新辅助化疗无反应的患者可接受紫杉烷类化疗，或在可行的情况下直接进行放疗，然后行改良根治性乳房切除术。全身治疗：激素治疗。可手术和不可手术肿瘤。对于肿瘤对激素有反应的绝经前和绝经后女性，应推荐服用他莫昔芬5年。局部区域治疗。可手术肿瘤。如果可行，IIIA期疾病患者应接受改良根治性乳房切除术（MRM）和局部区域放疗。他们可以先进行MRM，然后进行化疗和局部区域放疗，或者先进行化疗，然后进行MRM和局部区域放疗。保乳手术目前不是标准方法。局部区域放疗应包括胸壁、锁骨上和腋窝淋巴结。内乳照射的作用尚不清楚。不可手术肿瘤。对化疗有反应的IIIB期疾病患者应接受手术加局部区域放疗。对化疗有反应的IIIC期疾病患者的局部区域治疗尚不清楚，应个体化。化疗后疾病仍无法手术的患者应接受局部区域放疗，随后可行手术。
作者的原文由乳腺癌护理和治疗临床实践指南指导委员会成员修订。随后，来自加拿大各地的9位肿瘤学家提供了反馈。最终文件由指导委员会批准。
乳腺癌护理和治疗临床实践指南指导委员会由加拿大卫生部召集。完成日期：2003年12月。
