Azim Hatem A, Davidson Nancy E, Ruddy Kathryn J
From the Department of Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; University of Pittsburgh Cancer Institute and UPMC Cancer Center, Pittsburgh, PA; Department of Oncology, Mayo Clinic, Rochester, MN.
Am Soc Clin Oncol Educ Book. 2016;35:23-32. doi: 10.1200/EDBK_159069.
For the hundreds of thousands of premenopausal women who are diagnosed annually with endocrine-sensitive breast cancer, treatment strategies are complex. For many, chemotherapy may not be necessary, and endocrine therapy decision making is paramount. Options for adjuvant endocrine regimens include tamoxifen for 5 years, tamoxifen for 10 years, ovarian function suppression (OFS) plus tamoxifen for 5 years, and OFS plus an aromatase inhibitor for 5 years. There are modest differences in efficacy between these regimens, with a benefit from OFS most obvious among patients with higher-risk disease; therefore, choosing which should be used for a given patient requires consideration of expected toxicities and patient preferences. An aromatase inhibitor cannot be safely prescribed without OFS in this setting. Additional research is needed to determine whether genomic tests such as Prosigna and Endopredict can help with decision making about optimal duration of endocrine therapy for premenopausal patients. Endocrine therapy side effects can include hot flashes, sexual dysfunction, osteoporosis, and infertility, all of which may impair quality of life and can encourage nonadherence with treatment. Ovarian function suppression worsens menopausal side effects. Hot flashes tend to be worse with tamoxifen/OFS, whereas sexual dysfunction and osteoporosis tend to be worse with aromatase inhibitors/OFS. Pregnancy is safe after endocrine therapy, and some survivors can conceive naturally. Still, embryo or oocyte cryopreservation should be considered at the time of diagnosis for patients with endocrine-sensitive disease who desire future childbearing, particularly if they will undergo chemotherapy.
对于每年被诊断出患有内分泌敏感性乳腺癌的数十万绝经前女性来说，治疗策略很复杂。对许多人而言，化疗可能并非必要，而内分泌治疗的决策至关重要。辅助内分泌治疗方案的选择包括5年他莫昔芬、10年他莫昔芬、卵巢功能抑制（OFS）加5年他莫昔芬以及OFS加5年芳香化酶抑制剂。这些方案在疗效上存在适度差异，OFS的益处在高危疾病患者中最为明显；因此，为特定患者选择使用哪种方案需要考虑预期的毒性和患者偏好。在这种情况下，若无OFS，芳香化酶抑制剂不能安全地开具处方。需要进一步研究以确定诸如Prosigna和Endopredict等基因组检测是否有助于绝经前患者内分泌治疗最佳疗程的决策。内分泌治疗的副作用可能包括潮热、性功能障碍、骨质疏松和不孕，所有这些都可能损害生活质量并导致治疗依从性差。卵巢功能抑制会加重绝经副作用。他莫昔芬/OFS时潮热往往更严重，而芳香化酶抑制剂/OFS时性功能障碍和骨质疏松往往更严重。内分泌治疗后怀孕是安全的，一些幸存者可以自然受孕。尽管如此，对于有内分泌敏感性疾病且希望未来生育的患者，在诊断时应考虑胚胎或卵母细胞冷冻保存，特别是如果他们将接受化疗。
