乳腺癌的辅助治疗从临床指南走向临床实践讨论

1、会计学1乳腺癌的辅助治疗从临床指南走向临床乳腺癌的辅助治疗从临床指南走向临床实践讨论实践讨论Enough?Guidelines (NIH,NCCN, St-Gallen )Personal experience and local policyIndustry advertisingLiterature (individual studies, review)Reimbursementconditions，insurance policyAdjuvant onlineDefined as “systematically developed statementsto assist practit

2、ioner and patient decisionsabout appropriate health care for specific clinical circumstances”Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines, 1990. Different level of patient involvement in the decision making processPentheroudakis et al. Ann Oncol

3、. 2008;19:2067-2078. DFSOSProportional Risk reduction (relapse)Proportional Risk reduction (mortality)Hormonal therapy 40%32%Chemotherapy50%44%Combined therapy60%62%CMFMilanACB-15FEC50ICCG=CEFMA.5FACGEICAMTACBCIRG 001TCUS9735AC-PC9344B-28AC-TE1199AC-PwE1199AC2w-P2wC9741FEC100FASG05FEC-PwG9906FEC-TPA

4、CS01ST GALLENNCCNESMO化疗方案化疗方案Risk CategoryTreatmentPreferred ChemotherapyESMOIntermediateET alone orCT ETACMF, CEF, ACT, TAC, FECT, FEC100, ATCMFSt. GallenIntermediateET (consider + CT)Specific regimens not listedNCCN-Consider 21-gene assay or ET CTTAC, TC, ACP, AC CT = chemotherapy; ET = endocrine

5、therapyHECEPTIN? CT regimen？Risk CategoryTreatmentPreferred ChemotherapyTrastuzumabESMOMCT + HACMF, CEF, ACT, TAC, FECT, FEC100, ATCMF3-weekly x 1 ynot concurrent with anthraSt. GallenMCT + HNo specific regimenACPH, sequential HERA approach, TCHNCCN-CT + HTCH, ACPH, THFEC, ACTH CT = chemotherapy; ET

6、 = endocrine therapy; H=trastuzumabHECEPTIN. ACPH, TCHEndocrine-responsivenessCHEMOTHERAPYStandard efficacyStandard efficacy Superior efficacyCMF x 6FEC x 6AC x 4 P x 4 (or WP x 12)AC x 4 D x 4FEC x 3 D x 3 (PACS01)A x 3 D x 3 CMF x 3(BIG 02-98)A(E)C x 4 A(C) x 4 CMF x 3(TC x 4)TAC x 6 (BCIRG001)Dos

7、e-dense AC x 4 P x 4Regimens withdecreasedcardiac risk !D,T : docetaxelP : paclitaxelEndocrine-responsivenessAbsentUncertainHighlowIntermediateHighFECA(C) CMFACCMFEndocrine therapy Anthracyclines + taxane(e.g., FEC x 3 D x 3)FECA(C) CMFAnthracycline + taxaneRiskADD Endocrine therapyHow does reimburs

8、ement fit it? Best treatment vs best available treatmentImpact of todays guidelines on future developmentShould we design trials in areas where level of evidence is low?CMFMilanACB-15FEC50ICCG=CEFMA.5FACGEICAMTACBCIRG 001TCUS9735AC-PC9344B-28AC-TE1199AC-PwE1199AC2w-P2wC9741FEC100FASG05FEC-PwG9906FEC-TPACS01ST GALLENNCCNESMO化疗方案化疗方案Endocrine-responsivenessCHEMOTHERAPYEndocrine-responsivenessAbsentUncertainHighlowIntermediateHighFEC