末期乳癌治療新指引


  【24drs.com】國際乳癌專家組成的團隊發表了末期乳癌,特別是轉移乳癌治療的新指引;這些指引將登載於2012年1月版的The Breast期刊。
  
  領導這個指引發展小組的是葡萄牙里斯本Champalimaud癌症中心乳癌研究計畫與乳癌小組主任Fatima Cardoso醫師,以及達那-法柏癌症研究中心乳房腫瘤中心主任、哈佛醫學院醫學教授Eric Winer醫師。
  
  Cardoso醫師表示,這些指引定稿於11月3日至5日於里斯本舉辦的第一屆末期乳癌(ABC1)共識研討會,這場會議吸引了來自全球超過800名的與會學者,會議過程相當順利。
  
  她表示,我們聚集了世界上的頂尖專家,對各項聲明進行投票;我們很快就對每項議題達到共識;這些指引總結了有關末期轉移乳癌的建議。下一次的會議(ABC2)將產生後續版本的指引,將會針對局部末期乳癌,這是另一個類型的病症,在此次還未論述。
  
  Cardoso醫師表示,這些將是討論所有我們認為必須表述之議題的末期乳癌指引,因此它們可以適用於各國。
  
  她指出,國家綜合癌症網絡發表過一些指引,但是主要適用於美國,並沒有被醫師們廣泛依循。
  
  歐洲腫瘤學會在2006年開始這個工作小組,在2007年(Breast. 2007;16:9-10)發表了有關末期乳癌治療的一般建議與原則;之後在2009和2010年出版了詳細的討論與後續建議(J Natl Cancer Inst. 2009;101:1174-1181與2010;102:456-463)。不過,這項工作的進展不夠快速,顯然地,需要一個專門的共識研討會來產生涵蓋所有議題的更詳盡的指引。
  
  Winer醫師在聲明中表示,處置轉移性疾病往往缺乏可獲得快速進步且有實證照護標準的有力的國際性臨床和轉化研究,因此,病患與照護者通常會覺得很像處於各種不同意見與指引的迷宮中。
  
  Cardoso醫師在受訪時指出,新版指引強調的重點之一是,末期乳癌之治療應由跨科別團隊來進行,這是顯而易見的,也有付諸於紙本規範,但是,實務上卻沒有這麼做。
  
  目前,末期乳癌通常是由腫瘤科醫師獨自處置;因為少有確立的照護標準,各個醫師都是做自己認為對病患最好的方法,她表示,我們戲稱這是「以地位為基礎的醫學」。
  
  Cardoso醫師解釋,轉移乳癌通常不是最初的診斷,僅佔新案例的10%。她表示,在惡化病患比較常見,就算早期乳癌有被適當治療,仍約有30%的病患復發且出現轉移。
  
  Cardoso醫師指出,一旦乳癌擴散,將是難治癒的,她強調的是,雖然難治癒,但是可以治療的,我們希望傳遞的訊息是,就算難治癒,仍不應放棄。如果可以用現有的知識正確地治療,我們可以改善整體存活率。
  
  目前,醫學教科書估計末期乳癌可存活中位數為2到3年。但是,實際上,在我們的臨床實務中,有存活更久的案例。在ABC1研討會中,有轉移乳癌病患表示已經存活8到9年。
  
  她表示,我們希望他們不是例外,而是希望多數病患可以如此。我們從早期乳癌案例中知道,使用國際共識指引可改善存活— 現在,我們必須為轉移乳癌訂定同樣的指引,為此,我們需要幾項要件。
  
  她解釋,我們需釐清提供給病患的訊息,而這不是個可以簡單提出或理解的訊息。我們需要釐清,目標不在於治癒,而是控制疾病與轉為慢性情況。這並不是說這篇研究很聰明我們不用再繼續找到治癒方法。
  
  她表示,接下來,我們必須提供最佳照護。這必須由跨科別團隊於乳房專科機構提供,包括確認每種乳癌類型(例如 HER2-陽性、雌激素受體陽性、三重陰性)且據以提供治療。這是「客製化」的治療,已經在早期乳癌這樣進行,但是我們必須也對末期乳癌這樣做。
  
  最後,同樣重要的是緩和照護 — 特別的是,有效控制疼痛的簡單方法,包括不一定會使用的鴉片類製劑,有些病患因為一些阻礙而無法使用嗎啡,而遭受了不必要的疼痛。
  
  Cardoso醫師指出,男性也會有乳癌,ABC1會議並未忘記他們;有些特別針對男性末期乳癌病患的指引也有所討論。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6664&x_classno=0&x_chkdelpoint=Y
  

New Guidelines on Treatment of Advanced Breast Cancer

By Zosia Chustecka
Medscape Medical News

November 23, 2011 — New guidelines for the treatment of advanced breast cancer, specifically metastatic breast cancer, have been developed by an international group of breast cancer experts.

These guidelines are scheduled to be published in the January 2012 issue of The Breast.

They were developed by a task force chaired by Fatima Cardoso, MD, director of the breast cancer unit and breast cancer research program at the Champalimaud Cancer Center in Lisbon, Portugal, and Eric Winer, MD, professor of medicine at Harvard Medical School and director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, Massachusetts.

The guidelines were finalized at the first Advanced Breast Cancer (ABC1) consensus conference, held November 3 to 5 in Lisbon. The meeting attracted more than 800 participants from around the world, and "it went very well," Dr. Cardoso told Medscape Medical News.

"We had a panel of the world's leading experts, and voted on statements; we reached consensus on nearly everything," she said. The guidelines will summarize recommendations for advanced metastatic breast cancer.

A future meeting (ABC2), which will produce a future set of guidelines, will tackle locally advanced breast cancer, which is a separate entity and was not addressed this time around, she noted.

First Set of Guidelines

"These will be the first guidelines for advanced breast cancer that tackle all of the issues that we feel need to be addressed," Dr. Cardoso said." We designed them so that they can be adapted in all countries."

She noted that the National Comprehensive Cancer Network already has some guidelines, but they are specific to the United States and are not broadly adhered to by clinicians.

The work of the task force, set up by the European School of Oncology, started in 2006. A set of principles/general recommendations for the treatment of advanced breast cancer were published in 2007 (Breast. 2007;16:9-10); these were followed by the publication of detailed discussions and further recommendations in 2009 and 2010 (J Natl Cancer Inst. 2009;101:1174-1181 and 2010;102:456-463).

However, the work was not advancing fast enough. It became clear that a dedicated consensus guidelines conference was needed to produce a more detailed set of guidelines covering all of the issues, Dr. Cardoso explained.

"Management of metastatic disease has suffered from a lack of strong international collaboration in clinical and translational research that could lead to faster advances and evidenced-based care standards. As a result, patients and carers often feel lost in a maze of many different opinions and scattered guideline efforts," Dr. Winer said in a statement.

One of the points emphasized in the new guidelines is that the treatment of advanced breast cancer should be carried out by a multidisciplinary team, Dr. Cardoso reported in an interview. "This is so obvious that it hardly needs writing down," she said, "but it is not done in practice."

At the moment, advanced breast cancer is often managed by an oncologist working in isolation; because there are few established standards of care, individual doctors do what they consider is best for the patient. "We jokingly refer to this as eminence-based medicine," she said.

Improving Survival

Metastatic breast cancer is not the initial diagnosis very often; it accounts for only about 10% of new cases, Dr. Cardoso explained. It is seen more commonly in patients who progress. Even when early breast cancer is adequately treated, about 30% of patients relapse and present with metastases, she said.

It is incurable, but it is treatable.

Once breast cancer has spread, it is incurable, Dr. Cardoso noted. "It is incurable, but it is treatable," she emphasized. "This is the main message that we want to send out — that even though it is incurable, it is not something that you should give up on.... If it is treated correctly, with all the knowledge that we already have available, we can improve overall survival."

Currently, medical textbooks estimate the median survival for advanced breast cancer to be 2 to 3 years. "But in real life and in our clinical practice, we see examples of much longer survival," she said. At the ABC1 conference, there were patient advocates who have been living with metastatic breast cancer for 8 to 9 years.

"We want them not to be the exception, but to be the majority of patients with this disease," she said.

"We know from early-stage breast cancer that survival has improved with the use of international consensus guidelines — and now we must do the same for metastatic disease," she said. "To achieve that, we need several things."

"We need to be clear about the message we are giving to our patients, and it is not an easy message to give or to receive," she explained. "We need to be clear that we are not aiming for a cure, but we are aiming to control the disease and to turn it into a chronic condition.... This is not to say that research-wise, we should not continue to fight to find a cure."

"Next, we need to provide the best care. This is always provided by a multidisciplinary team and in specialized breast units," she said. This includes identifying each subtype of breast cancer (e.g., HER2-positive, estrogen-receptor positive, triple-negative), and treating them accordingly. "This is treatment tailoring. It is already being done in early breast cancer, but we must do it also in advanced disease," she said.

Last but not least is access to palliative care — in particular, "easy access to effective control of pain, including opiates, which does not always happen," she said. "Some patients do not even have access to morphine because of the hurdles that are placed in the way, and they suffer pain unnecessarily."

Men can also have breast cancer, albeit rarely, and they were not forgotten at ABC1; some guidelines specific for male patients with advanced breast cancer were also issued, Dr. Cardoso noted.

    
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