14 Ağustos 2008 Perşembe
effect of systemic treatment for advanced breast cancer
While metastatic disease is not curable, treatment can have a beneficial impact on length and quality of life.124 Chemotherapy and endocrine therapy are often effective, and local therapies such as palliative radiotherapy may be very useful.125 Ovarian suppression can be an effective treatment for those younger women with endocrine responsive cancers and retained ovarian function. The LHRH agonist goserelin is effective in suppressing ovarian function in premenopausal women with metastatic breast cancer, and is as beneficial as ovariectomy (oophorectomy) or ovarian irradiation in improving progressionfree and overall survival.126,127 The combination of LHRH agonist and tamoxifen is even more effective in premenopausal women, and significantly prolongs survival compared with LHRH agonist treatment alone.123
differences of Chemotherapy and endocrine therapy in breast cancer
However, it is important to note that the merits of chemotherapy compared with endocrine therapy for younger women are still being assessed. Trials to date have compared chemotherapy alone with endocrine therapy alone. Trials should now be designed to compare chemotherapy followed by tamoxifen with endocrine therapy alone. The current standard of care for women with hormone receptor positive tumours is treatment with both chemotherapy and endocrine therapy; however, some younger women with very good prognosis may decide to have endocrine therapy alone. Trials to determine the impact on disease outcome of chemotherapy plus endocrine therapy are continuing.
differences of Chemotherapy and endocrine therapy in breast cancer
However, it is important to note that the merits of chemotherapy compared with endocrine therapy for younger women are still being assessed. Trials to date have compared chemotherapy alone with endocrine therapy alone. Trials should now be designed to compare chemotherapy followed by tamoxifen with endocrine therapy alone. The current standard of care for women with hormone receptor positive tumours is treatment with both chemotherapy and endocrine therapy; however, some younger women with very good prognosis may decide to have endocrine therapy alone. Trials to determine the impact on disease outcome of chemotherapy plus endocrine therapy are continuing.
endocrine therapy in breast cancer
Combined data from four randomised trials involving 314 women aged less than 35 years indicate that women with hormone receptor positive tumours who did not have endocrine therapy after their chemotherapy had significantly worse disease-free survival than women with hormone receptor negative tumours.15 For premenopausal women with hormone receptor positive cancers, endocrine therapy currently comprises tamoxifen, ovarian suppression or both. Ovarian suppression can be achieved through surgical, radiotherapeutic or chemical means, which should be discussed with the woman as appropriate. Ovarian ablation by surgery or irradiation has been shown to improve long-term survival in women aged younger than 50 years, particularly in the absence of chemotherapy.1 Luteinizing hormone-releasing hormone (LHRH) agonists such as goserelin are effective in suppressing ovarian function chemically; this effect is potentially reversible following cessation of treatment.120 More is known about tamoxifen, which significantly improves recurrence-free and overall survival in women of all age groups and is recommended for most women with oestrogen receptor positive tumours (Level I).116
Treatment with tamoxifen for five years reduces the risk of disease recurrence by up to half in premenopausal women with oestrogen receptor positive cancers.116 This relative reduction in risk will be translated into different absolute benefits depending on individual patient factors.
Ongoing clinical trials are examining whether treatment with tamoxifen for more than five years is beneficial. An average effect of tamoxifen alone in women less than 50 years old would be to improve 10-year disease-free survival from 80% to 85% (small node negative tumour) or from 55% to 65% (small node positive tumour).118 Ovarian suppression may have similar effects. Indeed, in two recently published trials temporary ovarian suppression with goserelin for two years was found to be as effective for disease-free survival as chemotherapy,121 and ovarian
suppression plus tamoxifen was more effective than chemotherapy.122
Treatment with tamoxifen for five years reduces the risk of disease recurrence by up to half in premenopausal women with oestrogen receptor positive cancers.116 This relative reduction in risk will be translated into different absolute benefits depending on individual patient factors.
Ongoing clinical trials are examining whether treatment with tamoxifen for more than five years is beneficial. An average effect of tamoxifen alone in women less than 50 years old would be to improve 10-year disease-free survival from 80% to 85% (small node negative tumour) or from 55% to 65% (small node positive tumour).118 Ovarian suppression may have similar effects. Indeed, in two recently published trials temporary ovarian suppression with goserelin for two years was found to be as effective for disease-free survival as chemotherapy,121 and ovarian
suppression plus tamoxifen was more effective than chemotherapy.122
effect of chemotherapy in breast cancer
Women aged younger than 35 years have a particularly high risk of recurrence and should strongly consider treatment with chemotherapy.117
Clinicians should advise younger women that the benefit of chemotherapy is greater the younger the woman’s age. Chemotherapy will reduce the risk of recurrence by about one-fifth in women aged 60 to 69 years, but by nearly two-fifths in women under the age of 40.
The risk of recurrence never completely goes away. Clinical trials show that women aged younger than 50 years who had chemotherapy have lower rates of recurrence than those who did not, even 10 years after treatment.115 While a younger woman has a potentially long time at risk of recurrence, she also has a long time to accrue the benefit of adjuvant chemotherapy. The risk of recurrence depends on a number of factors, but an average effect of chemotherapy in women less than 50 years old would be to improve 10-year disease-free survival from 80% to 87% (small node negative tumour) or from 55% to 70% (small node positive tumour).118
Clinicians should advise younger women that the benefit of chemotherapy is greater the younger the woman’s age. Chemotherapy will reduce the risk of recurrence by about one-fifth in women aged 60 to 69 years, but by nearly two-fifths in women under the age of 40.
The risk of recurrence never completely goes away. Clinical trials show that women aged younger than 50 years who had chemotherapy have lower rates of recurrence than those who did not, even 10 years after treatment.115 While a younger woman has a potentially long time at risk of recurrence, she also has a long time to accrue the benefit of adjuvant chemotherapy. The risk of recurrence depends on a number of factors, but an average effect of chemotherapy in women less than 50 years old would be to improve 10-year disease-free survival from 80% to 87% (small node negative tumour) or from 55% to 70% (small node positive tumour).118
systemic therapy in breast cancer
Discussions between younger women and clinicians about systemic treatments should include consideration of the individual woman’s underlying risk of recurrence, her treatment preference and the associated toxicities of treatment.
Where there remains a significant risk of distant relapse following local therapy, systemic therapy is frequently given in order to reduce this risk.At present, such adjuvant systemic therapy consists of various cytotoxic chemotherapy regimens and endocrine measures, such as tamoxifen and ovarian suppression. Many clinical trials have been carried out to determine the extent to which giving chemotherapy, or endocrine therapy or both may reduce the risk of recurrence. Five-yearly systematic review and meta-analysis of these trials show that these treatments are effective, although endocrine treatments are only effective where the tumour expresses hormone receptors.1,115,116 The greater the risk of cancer recurrence, the greater the potential benefit from adjuvant therapies. For hormone receptor positive cancers, chemotherapy combined with endocrine therapy is better than either treatment alone.
Where there remains a significant risk of distant relapse following local therapy, systemic therapy is frequently given in order to reduce this risk.At present, such adjuvant systemic therapy consists of various cytotoxic chemotherapy regimens and endocrine measures, such as tamoxifen and ovarian suppression. Many clinical trials have been carried out to determine the extent to which giving chemotherapy, or endocrine therapy or both may reduce the risk of recurrence. Five-yearly systematic review and meta-analysis of these trials show that these treatments are effective, although endocrine treatments are only effective where the tumour expresses hormone receptors.1,115,116 The greater the risk of cancer recurrence, the greater the potential benefit from adjuvant therapies. For hormone receptor positive cancers, chemotherapy combined with endocrine therapy is better than either treatment alone.
psychosocial aspects of local cancer therapy
Younger women appear to experience more concerns about body image,98 greater emotional distress99,100 and poorer adjustment100 following breast surgery than older women.
There is little evidence to suggest a substantial difference in post-operative psychological morbidity according to type of surgery.101 However, some research suggests that younger women experience greater distress following mastectomy than breast conserving surgery.102 Women who undergo breast conserving surgery are also more likely to report better body image than those who have a mastectomy.103 Breast conserving surgery provides an opportunity to preserve the breast shape, facilitates a better fit of clothing, and usually avoids the need for a prosthesis or reconstructive surgery. Evidence that younger women are generally more likely to select breast conserving surgery over mastectomy87,101,104 suggests that concern for body image is an important consideration.
Several studies have reported that, for many young women, fear of cancer and recurrence are prevalent following surgery.50-52 Women may also experience sexual difficulties,105,106 such as a reluctance to resume sexual relations, loss of libido, or feelings of sexual unattractiveness.107
Breast reconstruction
Women report a number of benefits following reconstruction, including more positive body image,108 more positive partner attitudes,109,110 feeling more comfortable without a prosthesis,110 feeling ‘whole’ again, and thinking less about cancer.111,112
There has been little systematic research about age and reconstruction. One exception is a recent study that examined age-related patient satisfaction and psychosocial morbidity following surgery. Among women aged younger than 40 years, those who had breast conserving surgery or reconstruction were less likely to feel sexually unattractive or anxious, and reported more positive body image, than those who had a mastectomy alone.113 In one small randomised trial
involving 64 women aged younger than 60 years,women who received breast reconstruction had lower rates of psychological distress in the short term and improved body image at three and 12 months post-surgery compared with controls.114
There is little evidence to suggest a substantial difference in post-operative psychological morbidity according to type of surgery.101 However, some research suggests that younger women experience greater distress following mastectomy than breast conserving surgery.102 Women who undergo breast conserving surgery are also more likely to report better body image than those who have a mastectomy.103 Breast conserving surgery provides an opportunity to preserve the breast shape, facilitates a better fit of clothing, and usually avoids the need for a prosthesis or reconstructive surgery. Evidence that younger women are generally more likely to select breast conserving surgery over mastectomy87,101,104 suggests that concern for body image is an important consideration.
Several studies have reported that, for many young women, fear of cancer and recurrence are prevalent following surgery.50-52 Women may also experience sexual difficulties,105,106 such as a reluctance to resume sexual relations, loss of libido, or feelings of sexual unattractiveness.107
Breast reconstruction
Women report a number of benefits following reconstruction, including more positive body image,108 more positive partner attitudes,109,110 feeling more comfortable without a prosthesis,110 feeling ‘whole’ again, and thinking less about cancer.111,112
There has been little systematic research about age and reconstruction. One exception is a recent study that examined age-related patient satisfaction and psychosocial morbidity following surgery. Among women aged younger than 40 years, those who had breast conserving surgery or reconstruction were less likely to feel sexually unattractive or anxious, and reported more positive body image, than those who had a mastectomy alone.113 In one small randomised trial
involving 64 women aged younger than 60 years,women who received breast reconstruction had lower rates of psychological distress in the short term and improved body image at three and 12 months post-surgery compared with controls.114
Kaydol:
Kayıtlar (Atom)