Friedman Neil S, Shaham Lital, Sharon Nehama, Barlev Chani
Comprehensive Breast Cancer Unit, Laniado Medical Center.
Pediatric Hemato-Oncology Unit, Laniado Medical Center.
Harefuah. 2020 May;159(5):370-375.
Women who present with locally advanced breast cancer that would require a mastectomy are often recommended to undergo chemotherapy prior to surgery in hopes of down-staging the tumor and allowing for breast-conserving surgery. This approach is very effective in women with triple negative and Her2neu positive locally advanced breast cancer, yet the results in ER/PR positive (luminal) breast cancers have been less effective. In post-menopausal women, neoadjuvant hormonal treatment in such cases can cause tumor regression and allow for breast-conserving therapy, in some patients. In premenopausal women with locally advanced luminal type breast cancer, neoadjuvant hormonal therapy can also be effective and is a valid option according to the NCCN guidelines. Yet, there remains a sense that perhaps treatment of this group of patients with chemotherapy results in better outcomes. For the past fifteen years various molecular profiles of luminal breast cancers have been studied and have been used to help guide decisions as to the benefit of adjuvant treatment - whether chemotherapy is necessary or hormonal therapy alone would be adequate. In the neo-adjuvant setting, these profiles can also help predict which tumors are likely to respond to chemotherapy and which are less likely to respond. The only hormonal drugs available until very recently for use in the neoadjuvant setting were either Tamoxifen or an aromatase inhibitor. In the past few years a new class of drugs, CDK4/6 inhibitors have been developed and approved and have significantly improved response rates and time to progression in patients with metastatic hormone responsive breast cancer, and they have also been studied in small trials in the neoadjuvant setting. In this article we will review the data that is available to help guide the optimal choice of treatment in women who present with locally advanced luminal breast cancers including the use of molecular profiles and the potential role of anti-CDK 4/6 drugs.
对于那些患有局部晚期乳腺癌且需要进行乳房切除术的女性，通常建议在手术前接受化疗，以期缩小肿瘤分期并实现保乳手术。这种方法在三阴性和人表皮生长因子受体2（Her2neu）阳性的局部晚期乳腺癌女性中非常有效，但在雌激素受体（ER）/孕激素受体（PR）阳性（管腔型）乳腺癌中的效果较差。在绝经后女性中，这种情况下的新辅助激素治疗可使部分患者的肿瘤消退并实现保乳治疗。对于绝经前患有局部晚期管腔型乳腺癌的女性，新辅助激素治疗也可能有效，并且根据美国国立综合癌症网络（NCCN）指南，这是一种可行的选择。然而，人们仍然感觉，或许用化疗治疗这组患者会带来更好的结果。在过去的十五年里，人们对管腔型乳腺癌的各种分子特征进行了研究，并将其用于辅助治疗获益决策的指导——即是否需要化疗，还是仅激素治疗就足够。在新辅助治疗环境中，这些特征也有助于预测哪些肿瘤可能对化疗有反应，哪些不太可能有反应。直到最近，可用于新辅助治疗的唯一激素药物是他莫昔芬或芳香化酶抑制剂。在过去几年中，一类新型药物，即细胞周期蛋白依赖性激酶4/6（CDK4/6）抑制剂已研发并获批，显著提高了转移性激素反应性乳腺癌患者的缓解率和疾病进展时间，并且它们也在新辅助治疗环境的小型试验中得到了研究。在本文中，我们将回顾现有数据，以帮助指导患有局部晚期管腔型乳腺癌女性的最佳治疗选择，包括分子特征的应用以及抗CDK 4/6药物的潜在作用。
