Systemtherapie beim Mammakarzinom -
Adjuvante und neoadjuvante Therapie:
Aktueller Stand, aktuelle Studien

Zusammenfassung

Der Einsatz adjuvanter systemischer Therapien geht beim Mammakarzinom mit einer klaren Senkung der Rezidivwahrscheinlichkeit und einer Verlängerung des Gesamtüberlebens einher. Die adjuvante Behandlung sollte sich an den Konsensusempfehlungen von St. Gallen 2001 orientieren. Entscheidende prognostische und prädiktive Parameter für die Therapiewahl sind die Tumorgröße, das Ausmaß des axillären Lymphknotenbefalls, der Menopausenstatus, der Hormonrezeptorstatus und das Grading. Bei der Mehrzahl der Patientinnen, insbesondere bei Frauen mit hormonunempfindlichen Tumoren, ist eine adjuvante Chemotherapie indiziert. Anthrazyklinhaltige Therapien weisen einen kleinen, aber statistisch signifikanten Überlebensvorteil gegenüber nicht-anthrazyklinhaltigen Therapieprotokollen auf. Neuere Daten weisen der adjuvanten Hormontherapie einen hohen Stellenwert zu. Mit Ausnahme einer kleinen Gruppe von Patientinnen mit minimaler Rückfallwahrscheinlichkeit sollten alle Frauen mit hormonempfindlichen Tumoren eine antihormonelle Therapie erhalten. Grundlage ist eine Tamoxifen-Behandlung über 5 Jahre. Für prämenopausale Frauen stellt die Ausschaltung der Ovarialfunktion eine zusätzliche Option dar. Nicht abschließend geklärt ist derzeit die Frage der kombinierten Hormontherapie bzw. chemoendokriner Therapien bei Patientinnen mit hormonempfindlichen Tumoren. Der Stellenwert von Trastuzumab bzw. der Aromatasehemmer und der Bisphosphonate ist derzeit unklar. Präoperative medikamentöse Therapien sind beim inflammatorischen Mammakarzinom die Behandlungsform der Wahl. Multimodale Therapiekonzepte ermöglichen dabei eine Verlängerung der Überlebenszeit. Bei nicht-inflammatorischen Mammakarzinomen sind durch den Einsatz primärer systemischer Therapien organerhaltende Operationen häufiger möglich. Zudem ermöglichen sie eine Verbesserung prognostischer Aussagen und eine rasche Evaluierung neuer Therapieverfahren. Ein Überlebensvorteil ließ sich bei nicht-inflammatorischen Tumoren nicht nachweisen. Patientinnen mit einer pathologisch kompletten Remission nach der präoperativen Behandlung scheinen jedoch eine bessere Prognose aufzuweisen. Ausgenommen lokal fortgeschrittene Tumore, sollten präoperative medikamentöse Therapien klinischen Studien vorbehalten sein.

Abstract

Adjuvant systemic treatment has made a major impact on relapse-free and overall survival of patients with early-stage breast cancer. Recommendations for adjuvant treatment have been proposed by an international consensus panel in St. Gallen 2001. Treatment strategies are based on prognostic and predictive factors including tumour size, nodal status, menopausal status, hormone receptor status and grading. Adjuvant polychemotherapy is indicated in the majority of patients, especially in women with hormone-insensitive disease. Anthracycline-based regimens have been associated with a small but statistically significant advantage in overall survival compared to CMF-based regimens. Recent developments enhance the role of endocrine treatments. With the exception of patients with minimal-risk disease, all women with hormone-sensitive disease should be considered for hormonal therapy. Tamoxifen for 5 years is the most established adjuvant hormonal treatment. Ovarian ablation or suppression of the ovarian function are further promising options for premenopausal women. The role of combined hormonal or chemoendocrine treatment is currently unclear. The role of adjuvant treatment with trastuzumab, aromatase inhibitors or bisphosphonates has yet to be defined. Primary systemic therapy has become the treatment of choice for inflammatory breast cancer since combined modality approaches resulted in an improved survival. In non-inflammatory breast cancer, primary systemic treatment has generally failed to show an impact on survival. Only pathological complete response to primary treatment seems to be associated with a better prognosis. The use of primary systemic therapy can result in more frequent usage of breast conserving modalities. However, outside clinical trials, the use of preoperative systemic therapy should be restricted to locally-advanced disease.

Schlüsselwörter

Mammakarzinom - Adjuvante Therapie - Neoadjuvante Therapie - Tamoxifen - GURH-Analoga

Key words

Primary breast cancer - adjuvant treatment - primary systemic therapy - tamoxifen - ovarian ablation

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