Senologie - Zeitschrift für Mammadiagnostik und -therapie 2013; 10(1): 34-38
DOI: 10.1055/s-0033-1335037
Wissenschaftliche Arbeit
© Georg Thieme Verlag KG Stuttgart · New York

Prädiktive Biomarker beim ER+/HER2 – Mammakarzinom – Diskrepanz zwischen S3-Leitlinie, AGO-Empfehlung und St.-Gallen-Expertenmeinung

Predictive Biomarker of ER+/HER2– Breast Cancer – Discrepancies between German S3 Guideline, AGO Recommendation and St. Gallen Opinion of the Experts
J. C. Brase
1   Sividon Diagnostics, Köln
,
M. Schmidt
2   Klinik und Poliklinik für Geburtshilfe und Frauenheilkunde, Johannes-Gutenberg-Universität, Mainz
,
C. Denkert
3   Institut für Pathologie, Charité Universitätsmedizin Berlin, Berlin
,
H. Höfler
4   Institut für Allgemeine Pathologie und Pathologische Anatomie der Technischen Universität München, München
,
W. Jonat
5   Klinik für Gynäkologie und Geburtshilfe, UK-SH, Campus Kiel, Kiel
,
M. Dietel
3   Institut für Pathologie, Charité Universitätsmedizin Berlin, Berlin
› Author Affiliations
Further Information

Publication History

Publication Date:
08 March 2013 (online)

Zusammenfassung

Auch für die Behandlung von Brustkrebs bilden Leitlinien und Expertenkonsensus eine unverzichtbare Basis für eine evidenzbasierte Auswahl der Therapie. In Deutschland sind dies unter anderem die S3-Leitlinie der Deutschen Krebsgesellschaft, die Leitlinien der Arbeitsgemeinschaft Gynäkologische Onkologie und der Expertenkonsensus von St. Gallen. Durch sie wurden einheitliche Behandlungsstrategien erreicht und so wesentliche Fortschritte bei der Behandlung des Mammakarzinoms mit ermöglicht. Für die Entscheidung, ob Patientinnen mit einem luminalen Mammakarzinom der mittleren Risikogruppe mit einer chemo-endokrinen Therapie behandelt werden sollten oder ob eine einfache Hormontherapie ausreicht, stellen die verwendeten Leitlinien jedoch weiterhin keine allgemein anerkannten und einem medizinischen Standard genügende Verfahren dar. Dies wird besonders bei der divergierenden Einschätzung der Anwendbarkeit von Proteasen, Ki67 und Genexpressionstests deutlich. Sie wurden als neuere diagnostische Verfahren eingeführt, um die auf der Basis der klassischen klinisch-pathologischen Entscheidungskriterien unbestritten unbefriedigende Therapiestratifizierung der beschriebenen Patientinnen zu verbessern. Zurzeit lassen sich die Argumente einer vordergründig besseren Validierung der einen Methode gegen die anscheinend bessere diagnostische Leistungsfähigkeit der anderen Methode, anders als manche Leitlinie meint feststellen zu müssen, nicht objektiv beurteilen. Dies ist keine Schwäche des Konzepts von Leitlinien oder der daran beteiligten Protagonisten. Es ist der Preis des rapiden Fortschritts in der Medizin. Gleichzeitig ist es aber Verpflichtung für die behandelnden Senologen und Pathologen als Experten in ihrem Gebiet, diesen medizinischen Fortschritt mit Augenmaß und schon vor einer umfassenden Konsolidierung der Leitlinien für eine sicherere und zielgerichtetere Behandlung ihrer Patientinnen einzusetzen.

Abstract

Clinical guidelines and experts’ consensus form an important basis for the evidence based selection of therapies against breast cancer. The S3 guideline of the Deutsche Krebsgesellschaft, of the Arbeitsgemeinschaft Gynäkologische Onkologie and the experts’ consensus of St. Gallen are among the important guidelines for clinical use in Germany. Substantial progress in the management of breast cancer patients was achieved by introducing these guidelines into daily practice. Nevertheless, the key decision whether to employ chemo-endocrine therapy or a less aggressive hormonal treatment remains ambiguous for most patients with luminal tumors. The guidelines still fail to provide a generally accepted and objective standard to stratify such patients for therapy. This is stressed by the strikingly divergent assessment of the clinical usability of proteases, Ki67 and gene expression tests. These methods were introduced to improve the non-debatably poor therapy stratification of the aforementioned patient cohort based on classical clinico-pathological criteria alone. Contrasting some guidelines, at this point, it appears impossible to balance the arguments for an ostensibly superior validation of one method against the case for an apparently superior diagnostic performance of another approach. Clearly, this disagreement does not demonstrate any weakness of the concept of therapy guidelines or their protagonists. It is the price to pay for the rapid progress in medicine. At the same time it marks the obligation of the treating oncologists and pathologists to employ this medical progress for a more secure and more targeted treatment of their patients even before the consolidation of all guidelines has been accomplished.

 
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