美国医学会杂志：乳腺癌诊治常识

　　每年，超过25万美国人被诊断出乳腺癌。

　　2019年1月22日，《美国医学会杂志》正刊发表哈佛大学医学院、达纳法伯癌症研究所的患者教育，描述了乳腺癌不同类型和分期的诊断与治疗。

达纳法伯癌症研究所：哈佛大学医学院、哈佛大学公共卫生学院的教学医院之一，1947年由西德尼·法伯（现代化疗之父、儿童白血病医生）创建，1974年被命名为西德尼·法伯癌症研究所，1983年由查尔斯·安德森·达纳（美国记者、作家、官员，先后担任纽约论坛报和纽约太阳报总编、美国陆军助理部长）基金会提供支持，更名为达纳法伯癌症研究所。

　　乳腺癌的诊断与分期

　　当乳腺细胞开始失控时，发生乳腺癌。许多乳腺癌在乳腺钼靶（专门用于仔细观察乳腺组织的X线扫描）检查时被诊断，部分乳腺癌在女性自己或其医生发现乳房异常肿块时被诊断，少数乳腺癌最初表现为乳房皮肤或乳头的变化。

　　在诊断时，乳腺癌细胞可能被发现于乳腺组织、手臂下方腋窝淋巴结、或者体内更远部位。根据癌症被发现的部位，乳腺癌被分为Ⅰ～Ⅳ期。Ⅳ期乳腺癌又称转移性乳腺癌，乳腺癌已经扩散至体内远离乳房和腋窝淋巴结的部位。

　　乳腺癌的类型

　　根据乳腺癌细胞不同蛋白质的存在与否，乳腺癌被分为三种类型：

• 激素受体阳性乳腺癌：约占乳腺癌病例的70%，癌细胞存在雌激素受体或孕激素受体的蛋白质；

• HER2阳性乳腺癌：约占乳腺癌病例的15%～20%，癌细胞存在高水平的HER2蛋白质；

• 三阴性乳腺癌：约占乳腺癌病例的15%，癌细胞无雌激素受体、孕激素受体或HER2的蛋白质。

　　乳腺癌的预后与治疗

　　大多数美国乳腺癌患者并未死于乳腺癌。与每年新诊断的25万例病例相比，每年死于乳腺癌4.1万例。乳腺癌的预后和治疗取决于乳腺癌的分期和类型。

　　每个治疗计划都是个体化的，应该由患者和癌症医生共同制定。

• 对于Ⅰ～Ⅲ期乳腺癌患者，治疗的目标是治愈乳腺癌。通常治疗包括手术切除乳房肿瘤、药物、以及可能的乳房放疗。

• 对于已经扩散至身体远处部位的Ⅳ期乳腺癌患者，治疗的目标是尽可能长期控制乳腺癌。Ⅳ期乳腺癌治疗以药物为主。

　　不同类型的乳腺癌对不同的药物有效。

• 激素受体阳性乳腺癌首选抗雌激素药物治疗，一些患者也需要静脉化疗。

• HER2阳性乳腺癌需要静脉注射专门攻击异常HER2蛋白药物以及静脉化疗。

• 三阴性乳腺癌目前主要依靠静脉化疗。

JAMA. 2019 Jan 22;321(3):316-316.

Breast Cancer Treatment.

Adrienne G. Waks; Eric P. Winer.

Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.

This JAMA Patient Page describes the diagnosis and treatment of different types and stages of breast cancer.

Breast cancer is diagnosed in more than 250000 people in the United States each year.

Diagnosis and Stages of Breast Cancer

Breast cancer occurs when cells in the breast begin to grow out of control. Many breast cancers are diagnosed based on a mammogram, a specialized x-ray scan designed to look closely at breast tissue. Some breast cancers are diagnosed when a woman or her doctor finds an abnormal lump in her breast. Rarely, changes in the skin or nipple of the breast can be the first sign of a breast cancer.

At diagnosis, breast cancer cells may be found in the breast tissue only, in the axillary lymph nodes under the arm, or in more distant sites in the body. Based on where the cancer is found, breast cancer is assigned a stage, from I to IV. Stage IV breast cancer, also called metastatic breast cancer, is breast cancer that has spread to a place in the body distant from the breast and axillary lymph nodes.

Types of Breast Cancer

Breast cancer is divided into 3 types based on the presence or absence of different proteins in the breast cancer cells. Hormone receptor-positive breast cancer makes up 70% of breast cancer cases and has either estrogen receptor (ER) or progesterone receptor (PR) protein in the cancer cells; ERBB2-positive (formerly known as HER2-positive) breast cancer makes up 15% to 20% of breast cancer cases and has high levels of ERBB2 protein on the cancer cells; and triple-negative breast cancer makes up 15% of breast cancer cases and does not have ER, PR, or ERBB2 protein in the cancer cells.

Prognosis and Treatment of Breast Cancer

Most people in the United States who have breast cancer diagnosed do not die of their breast cancer. Compared with the 250000 cases diagnosed annually, 41000 deaths due to breast cancer occur each year. The prognosis and treatment of breast cancer depend on the stage and the type of breast cancer.

Each treatment plan is individualized and should be made together by a patient and a cancer doctor. For patients with stage I to III breast cancer, the goal of treatment is to cure the breast cancer. Usual treatment consists of surgery to remove the breast tumor, medicines, and possibly radiation therapy to the breast. For patients with stage IV breast cancer, which has spread to a distant part of the body, the goal of treatment is to control the breast cancer for as long as possible. Treatment for stage IV breast cancer consists mainly of medicines.

Different types of breast cancer respond to different medicines. Hormone receptor-positive breast cancer is best treated with anti-estrogen pills. Some patients need intravenous chemotherapy infusions as well. ERBB2-positive breast cancer is treated with intravenous medicines that specifically attack the abnormal ERBB2 protein along with intravenous chemotherapy. Triple-negative breast cancer is treated with intravenous chemotherapy.

DOI: 10.1001/jama.2018.20751