乳房肿瘤，良性恶性，男女长幼都包括。
这里只说恶性的，乳癌的治疗取向和步骤，供参考判断。
乳癌，要进一步分类 年龄， 性别，整个身体健康状况，有无其它较严重的疾患，停经前或后（年龄），组织病理学，组化，组免疫学定性，临床分期，经治医生应尽所能给患者提供各选项利弊，使患者决断主意，配合治疗及康复。
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1）局部治疗 有二
2）全身系统治疗 有四
- Chemotherapy for Breast Cancer 化学药物治疗
- Hormone Therapy for Breast Cancer 激素治疗
- Targeted therapy for Breast Cancer 靶向治疗
- Immunotherapy for Breast Cancer 免疫治疗
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靶向疗法
专门针对表面有Her2/neu蛋白质的癌细胞。靶 向疗法的曲妥珠单抗（赫赛汀）通过静脉注射给药，每 周（或者每三周）一次，为期一年。 副作用包括心脏问题、腹泻、皮疹、嘴
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3）按乳癌分级分期治疗
Stage 0 零期 也称 原位癌
Stage 0 cancer means that the cancer is limited to the inside of the milk duct and is a non-invasive cancer. The treatment approaches for these non-invasive breast tumors are often different from the treatment of invasive breast cancer. Stage 0 breast tumors include ductal carcinoma in situ (DCIS).
Lobular carcinoma in situ (LCIS) used to be categorized as Stage 0 but this has been changed, because it is not cancer, but does indicate a higher risk of breast cancer. Look for more information about LCIS in Non-cancerous Breast Conditions.
Stages I to III Treatment 一期 二期 三期 乳癌治疗
for stages I to III breast cancer usually includes surgery and radiation therapy, often along with chemo or other drug therapies either before or after surgery.
Stage I:
These breast cancers are still relatively small and either have not spread to the lymph nodes or have only a tiny area of cancer spread in the sentinel lymph node (the first lymph node to which cancer is likely to spread).
Stage II:
These breast cancers are larger than stage I cancers and/or have spread to a few nearby lymph nodes.
Stage III:
These tumors are larger or are growing into nearby tissues (the skin over the breast or the muscle underneath), or they have spread to many nearby lymph nodes.
Stage IV (metastatic breast cancer) 四期 即癌瘤已有远处转移的癌
Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. Treatment for stage IV breast cancer is usually a systemic (drug) therapy.
Inflammatory breast cancer 炎性乳癌（其实是三期或四期乳癌的一个类型）
Inflammatory breast cancer (IBC) can be either stage III or stage IV, depending on whether it has spread to other parts of the body. Treatment for IBC can include chemo or other systemic therapies, local therapies such as radiation, and surgery.
Recurrent breast cancer 复发性乳癌
Cancer is called recurrent when it comes back after treatment. Recurrence can be local (in the same breast or in the surgery scar), regional (in nearby lymph nodes), or in a distant area. Treatment for recurrent breast cancer depends on where the cancer recurs and what treatments you’ve had before.
Triple-negative breast cancer 三受体阴性的乳癌
Triple-negative breast cancer cells don’t have estrogen or progesterone receptors and also don’t have too much of the protein called HER2.
Triple-negative breast cancers grow and spread faster than most other types of breast cancer. Because the cancer cells don’t have hormone receptors, hormone therapy is not helpful in treating these cancers. And because they don’t have much HER2, drugs that target HER2 aren’t helpful, either.
Chemotherapy is usually the standard treatment.
An immunotherapy drug, atezolizumab (Tecentriq), has been approved for use along with the chemotherapy drug, albumin-bound paclitaxel (Abraxane), for people with advanced triple negative breast cancer whose tumor makes the PD-L1 protein.
Because there are not many current treatments for this type of breast cancer, if you are in otherwise good health, you might want to think about taking part in a clinical trial testing a newer treatment.
【本文素材资料主要取自 美国肿瘤协会 American Cancer Society 2019年最新信息】
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激素治疗
About 2 out of 3 breast cancers are hormone receptor-positive. Their cells have receptors (proteins) that attach to the hormones estrogen (ER-positive cancers) and/or progesterone (PR-positive cancers). For these cancers, high estrogen levels help the cancer cells grow and spread.
There are several types of hormone therapy, which use different ways to keep estrogen from helping the cancer grow. Most types of hormone therapy for breast cancer either lower estrogen levels or stop estrogen from acting on breast cancer cells.
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about 1 in 5 women with breast cancer, the cancer cells have too much of a growth-promoting protein known as HER2/neu (or just HER2) on their surface. These cancers, known as HER2-positive breast cancers, tend to grow and spread more aggressively. A number of drugs have been developed that target this protein:
- Trastuzumab (Herceptin): This is a monoclonal antibody, which is a man-made version of a very specific immune system protein. It is often given along with chemo, but it might also be used alone (especially if chemo alone has already been tried). Trastuzumab can be used to treat both early- and late-stage breast cancer. When started before or after surgery to treat early breast cancer, this drug is usually given for a total of 6 months to a year. For advanced breast cancer, treatment is often given for as long as the drug is helpful. This drug is given into a vein (IV) and is infused over 30-90 minutes. Another type of trastuzumab called trastuzumab and hyaluronidase-oysk injection (Herceptin Hylecta) is also available. It is given as a subcutaneous (under the skin) shot that takes about 2 to 5 minutes to inject.
- Pertuzumab (Perjeta): This monoclonal antibody can be given with trastuzumab and chemo, either before surgery to treat early-stage breast cancer, or to treat advanced breast cancer. This drug is given into a vein (IV).
- Ado-trastuzumab emtansine (Kadcyla, also known as TDM-1): This is a monoclonal antibody attached to a chemotherapy drug. It is used by itself to treat advanced breast cancer in women who have already been treated with trastuzumab and chemo. This drug is also given in a vein (IV).
- Lapatinib (Tykerb): This is a kinase inhibitor. It is a pill taken daily. Lapatinib is used to treat advanced breast cancer, and might be used along with certain chemotherapy drugs, trastuzumab, or hormone therapy drugs.
- Neratinib (Nerlynx): This is another kinase inhibitor. It is a pill that is taken daily. Neratinib is used to treat early-stage breast cancer after a woman has completed one year of trastuzumab and is usually given for one year. Some clinical trials show that it may also be effective in advanced breast cancer, as well.
Side effects of targeted therapy for HER2-positive breast cancer
The side effects of these drugs are often mild, but some can be serious. Discuss what you can expect with your doctor.
Some women develop heart damage during or after treatment with trastuzumab, pertuzumab, or ado-trastuzumab emtansine. This can lead to congestive heart failure. For most (but not all) women, this effect lasts a short time and gets better when the drug is stopped. The risk of heart problems is higher when these drugs are given with certain chemo drugs that also can cause heart damage, such as doxorubicin (Adriamycin) and epirubicin (Ellence). Because these drugs can cause heart damage, doctors often check your heart function (with an echocardiogram or a MUGA scan) before treatment, and again while you are taking the drug. Let your doctor know if you develop symptoms such as shortness of breath, leg swelling, and severe fatigue.
Lapatinib and neratinib can cause severe diarrhea, so it’s very important to let your health care team know about any changes in bowel habits as soon as they happen. Lapatinib can also cause hand-foot syndrome, in which the hands and feet become sore and red, and may blister and peel. Pertuzumab can also cause diarrhea.
If you are pregnant, you should not take these drugs. They can harm and even cause death to the fetus. If you could become pregnant, talk to your doctor about using effective birth control while taking these drugs.
Targeted therapy for hormone receptor-positive breast cancer
About 2 of 3 breast cancers are hormone receptor-positive (ER-positive or PR-positive). For women with these cancers, treatment with hormone therapy is often helpful. Certain targeted therapy drugs can make hormone therapy even more effective, although these targeted drugs might also add to the side effects.
CDK4/6 inhibitors
Palbociclib (Ibrance), ribociclib (Kisqali), and abemaciclib (Verzenio) are drugs that block proteins in the cell called cyclin-dependent kinases (CDKs), particularly CDK4 and CDK6. Blocking these proteins in hormone receptor-positive breast cancer cells helps stop the cells from dividing. This can slow cancer growth.
These drugs are approved for women with advanced hormone receptor-positive, HER2-negative breast cancer and are taken as pills, typically once or twice a day.
There are different ways to use these drugs.
- Any of the three drugs can be given along with an aromatase inhibitor (such as letrozole) or fulvestrant to women who have gone through menopause.
- Palbociclib or abemaciclib can be given with fulvestrant to women who are still having regular periods (premenopausal) or are almost in menopause (perimenopausal). These women, however, must also be on medicines, such as luteinizing hormone-releasing hormone (LHRH) analogs, that stop the ovaries from making estrogen.
- Ribociclib can be given with an aromatase inhibitor to women who have not gone through menopause. Again, these women must also be on medicines that suppress the ovaries, such as a luteinizing hormone-releasing hormone (LHRH) analogs.
Abemaciclib can also be used by itself in women who have previously been treated with hormone therapy and chemotherapy.
Side effects of these drugs tend to be mild. The most common side effects are low blood cell counts and fatigue. Nausea and vomiting, mouth sores, hair loss, diarrhea, and headache are less common side effects. Very low white blood cell counts can increase the risk of serious infection.
Everolimus (Afinitor)
Everolimus is used for women who have gone through menopause and have advanced hormone receptor-positive, HER2-negative breast cancer. It is used along with the aromatase inhibitor exemestane (Aromasin) for women whose cancers have grown while being treated with either letrozole or anastrozole (or if the cancer started growing shortly after treatment with these drugs was stopped).
This targeted therapy drug blocks mTOR, a protein in cells that normally helps them grow and divide. Everolimus may also stop tumors from developing new blood vessels, which can help limit their growth. In treating breast cancer, this drug seems to help hormone therapy drugs work better. Everolimus is a pill that is taken once a day.
Common side effects of everolimus include mouth sores, diarrhea, nausea, feeling weak or tired, low blood counts, shortness of breath, and cough. Everolimus can also increase blood lipids (cholesterol and triglycerides) and blood sugars, so your doctor will check your blood work periodically while you are taking this drug. It can also increase your risk of serious infections, so your doctor will watch you closely for infection.
Everolimus is also being studied for use in earlier-stage breast cancer, with other hormone therapy drugs, and in combination with other treatments.
Targeted therapy for women with BRCA gene mutations
Olaparib (Lynparza) and talazoparib (Talzenna) are drugs known as PARP inhibitors. PARP proteins normally help repair damaged DNA inside cells. The BRCA genes (BRCA1 and BRCA2) also help repair DNA (in a slightly different way), but mutations in one of those genes can stop this from happening. PARP inhibitors work by blocking the PARP proteins. Because tumor cells with a mutated BRCA gene already have trouble repairing damaged DNA, blocking the PARP proteins often leads to the death of these cells.
Olaparib and talazoparib can be used to treat metastatic, HER2-negative breast cancer in women with a BRCA mutation who have already gotten chemotherapy. Olaparib can also be used in women who have already received hormone therapy if the cancer is hormone receptor-positive. Only a small portion of women with breast cancer have a mutated BRCA gene. If you are not known to have a BRCA mutation, your doctor will test your blood to be sure you have one before starting treatment with this drug.
These drugs come in pills that are taken once a day.
Side effects can include nausea, vomiting, diarrhea, fatigue, loss of appetite, taste changes, low red blood cell counts (anemia), low platelet counts, low white blood cell counts, belly pain, and muscle and joint pain. Rarely, some people treated with a PARP inhibitor have developed a blood cancer, such as myelodysplastic syndrome or acute myeloid leukemia (AML).
Targeted therapy for cancers with a PIK3CA gene mutation
Alpelisib (Piqray) is a targeted drug known as a PI3K inhibitor. It can be used along with fulvestrant to treat postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer with a PIK3CA mutation that has grown during or after treatment with an aromatase inhibitor. About 30-40% of breast cancers have a mutated PIK3CA gene. Your doctor will test your blood or tumor for this mutation before starting treatment with this drug.
This drug comes in pills that are taken once a day.
Side effects can include high blood sugar levels, signs of kidney, liver, or pancreatic problems, diarrhea, rash, low blood counts, nausea and vomiting, fatigue, decreased appetite, mouth sores, weight loss, low calcium levels, blood clotting problems, and hair loss. Very severe skin reactions, such as rashes with peeling and blistering, are possible and should be reported to a doctor. Patients with a history of severe skin reactions should tell their doctor before taking alpelisib.
Immunotherapy
is the use of medicines to stimulate a person’s own immune system to recognize and destroy cancer cells more effectively. Immunotherapy can be used to treat some types of breast cancer.
Immune checkpoint inhibitors
An important part of the immune system is its ability to keep itself from attacking normal cells in the body. To do this, it uses “checkpoints” – proteins on immune cells that need to be turned on (or off) to start an immune response. Breast cancer cells sometimes use these checkpoints to avoid being attacked by the immune system. Drugs that target these checkpoints, known as immunotherapy drugs, help to restore the immune response against the breast cancer cells.
PD-L1 inhibitors
Atezolizumab (Tecentriq) targets PD-L1, a protein that is found on some tumor cells and immune cells. Blocking this protein can help boost the immune response against breast cancer cells. This can shrink some tumors or slow their growth.
Atezolizumab can be used along with Abraxane (albumin-bound paclitaxel) in people with advanced triple negative breast cancer whose tumor makes the PD-L1 protein. It can be used as part of the first treatment in some people.
Atezolizumab is given as an intravenous (IV) infusion every 2 weeks.
Possible side effects
Side effects of atezolizumab can include fatigue, cough, nausea, loss of appetite, constipation, and diarrhea.
Other, more serious side effects occur less often. Immunotherapy drugs work by basically removing the brakes on the body’s immune system. Sometimes the immune system starts attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, or other organs.
It’s very important to report any new side effects to your health care team quickly. If serious side effects do occur, treatment may need to be stopped and you may get high doses of corticosteroids to suppress your immune system.
More information about immunotherapy
To learn more about how drugs that work on the immune system are used to treat cancer, see Cancer Immunotherapy.
To learn about some of the side effects listed here and how to manage them, see Managing Cancer-related Side Effects.
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