JustAnswer のしくみ:
  • 専門家に質問
    知識豊富な専門家があらゆる質問にお答えするために常に待機しています。
  • 専門家が丁寧に対応
    E メールやサイト内オンラインメッセージなど、さまざまな手段で回答を通知。
    必要に応じてフォローアップの質問をすることもできます。
  • 満足度 100% 保証
    専門家からの回答を確認し評価をすることで、支払うかどうかを決めます。
Dr_GATOに今すぐ質問する
Dr_GATO
Dr_GATO, 医師、医学博士
カテゴリ: 医療
満足したユーザー: 4035
経験:  1987年: 山梨医科大学を卒業。米国に留学中。米国のJustAnswerで5137人、96%のプラス評価。米国医師国家試験合格
70092855
ここに 医療 に関する質問を入力してください。
Dr_GATOがオンラインで質問受付中

53歳の妻が5年前にに乳がんを発症し、切除後ホルモン療法(タモキシフェン)を行ってきました。 5年目の今年6月の検

解決済みの質問:

53歳の妻が5年前にに乳がんを発症し、切除後ホルモン療法(タモキシフェン)を行ってきました。
5年目の今年6月の検査で、肝臓への転移(5.5〜6cmの腫瘍)が発見されました。肝臓のみで、その他への転移はみとめられていません。主治医位と相談の上、別なホルモン療法(アロ マターゼ阻害薬)の治療を約1ヶ月半行って、効果があれば継続、なければ化学療法へ切り替えることとしました。
(1) 1年前の検査では異常がなかったとのことですが、1年間で腫瘍が急激にここまで大きくなるものなのでしょうか?
(2) これほど急激に増殖するのであれば、1ヶ月半効果を見るというペースの治療で手遅れにならないのでしょうか?
(3) ホルモン療法(タモキシフェン)で効果がなくなってきているのに、アロマターゼ阻害薬で効果が期待できるのでしょうか?
投稿: 4 年 前.
カテゴリ: 医療
専門家:  Dr_GATO 返答済み 4 年 前.
(1) その可能性はあります。
(2)、(3) アロマターゼ阻害薬はわずかながらアロマターゼ阻害薬の方が高い。しかし、骨粗鬆症により骨折を起こす可能性があるので骨密度が低下している人には、ビスフォスフォネートの使用を考慮する必要があります。化学療法の方がホルモン療法より高く急速な反応があります。両者の併用はその副作用が増大するだけで化学療法ト比べてその反応に違いは認められていません。アロマターゼ阻害薬を用いずに直ちに化学療法を開始した方が良いと思います。
質問者: 返答済み 4 年 前.

下記の意味がわかりません。


何が高いのでしょうか?


 


「アロマターゼ阻害薬はわずかながらアロマターゼ阻害薬の方が高い。」

専門家:  Dr_GATO 返答済み 4 年 前.
申し訳ありません。訂正します。
ホルモン療法ではわずかながらアロマターゼ阻害薬の方がタモキシフェンより治療効果が高いようです。
質問者: 返答済み 4 年 前.

アロマターゼ阻害薬の方がタモキシフェンより治療効果が高くても、アロマターゼ阻害薬を用いずに直ちに化学療法を開始した方が良いと思われる理由は何でしょうか?


主治医は、それぞれのメリット、デメリット、リスクを判断して治療方針を決めていると思いますが。


専門家:  Dr_GATO 返答済み 4 年 前.
アロマターゼ阻害薬の方がタモキシフェンより多少治療効果が高いだけです。臨床報告では再発の場合,化学療法がアロマターゼ阻害薬を含むホルモン療法より治療効果が高く,直ぐにその効果が表れると報告されています。しかし,その生存期間には有為な違いは見られません。クオリテーオブライフに関しては化学療法では嘔気,嘔吐,脱毛が認められますが,化学療法のほうがホルモン療法よりクオリテーオブライフは高いと報告されています。
次の文献を担当医に読んでもらってください。

It is commonly thought that chemotherapy results in higher response rates and more rapid responses than endocrine therapy, and is often used as the initial treatment for patients with hormone receptor-positive metastatic breast cancer with a poor prognosis, especially those with visceral metastases. A meta-analysis that included eight small randomized trials, all published prior to 1995, compared the response rates for chemotherapy alone with those of endocrine therapy alone [65]. The pooled estimate of response rates showed an advantage for chemotherapy over endocrine therapy (relative risk 1.25, 95% CI 1.01 to 1.54), although the two largest trials had opposite findings [66,67]. No significant difference was seen in overall survival (hazard ratio, HR 0.94, 95% CI 0.79 to 1.12), and on subset analysis, there was no obvious trend to suggest an effect of age, menopausal status, or pattern of metastatic disease on the efficacy of either therapy. There was minimal and contrasting information on quality of life and toxicity.
A major limitation to these findings is that most patients in these trials had tumors of unknown hormone receptor status, since the predictive value of hormone receptor status on response to endocrine therapy was not yet appreciated. Nevertheless, chemotherapy remains the preferred modality for initial treatment of patients with rapidly progressive symptomatic disease or visceral crisis (end-organ dysfunction), given the higher likelihood of achieving a response with chemotherapy.
No survival benefit has been seen when chemotherapy and endocrine therapy were combined.

(References)

65
PubMed
TIChemotherapy alone versus endocrine therapy alone for metastatic breast cancer.
AUWilcken N, Hornbuckle J, Ghersi D
SOCochrane Database Syst Rev. 2003;

BACKGROUND: Both chemotherapy and endocrine therapy can be used as treatments for metastatic breast cancer.
OBJECTIVES: To review the evidence and determine whether chemotherapy or endocrine therapy has the most beneficial effect on treatment outcomes (survival, response rate, toxicity and quality of life).
SEARCH STRATEGY: The specialised register maintained by the Editorial Base of the Cochrane Breast Cancer Group was searched on 16th September 2002 using the codes for "advanced breast cancer", "chemotherapy" and "endocrine therapy". Details of the search strategy applied by the Group to create the register, and the procedure used to code references, are described in the Group's module on the Cochrane Library.
SELECTION CRITERIA: Randomised trials comparing the effects of chemotherapy alone with endocrine therapy alone on pre-specified endpoints in metastatic breast cancer.
DATA COLLECTION AND ANALYSIS: Data were collected from published trials. Hazard ratios were derived for survival analysis and a fixed effect model was used for meta-analysis. Response rates were analysed as dichotomous variables. Toxicity and quality of life data were extracted where present.
MAIN RESULTS: The primary analysis of overall effect using hazard ratios derived from published survival curves involved six trials (692 women). There was no significant difference seen (HR=0.94, 95%CI 0.79-1.12, p=0.5). A test for heterogeneity was p=0.1. A pooled estimate of reported response rates in eight trials involving 817 women shows a significant advantage for chemotherapy over endocrine therapy with RR=1.25 (1.01-1.54, p=0.04). However the two largest trials showed trends in opposite directions, and a test for heterogeneity was p=0.0018. There was little information available on toxicity and quality of life. Six of the seven fully published trials commented on increased toxicity with chemotherapy, mentioning nausea, vomiting and alopecia. Three of the seven mentioned aspects of quality of life, with differing results. Only one trial formally measured quality of life, concluding that it was better with chemotherapy.
REVIEWER'S CONCLUSIONS: In women with metastatic breast cancer and where hormone receptors are present, a policy of treating first with endocrine therapy rather than chemotherapy is recommended except in the presence of rapidly progressive disease.
ADDepartment of Medical Oncology, Westmead Hospital, Westmead, NSW, Australia.XXX@XXXXXX.XXX
PMID12804433

66
PubMed
TICombination chemotherapy compared to tamoxifen as initial therapy for stage IV breast cancer in elderly women.
AUTaylor SG 4th, Gelman RS, Falkson G, Cummings FJ
SOAnn Intern Med. 1986;104(4):455.

In a randomized crossover study, 181 patients over the age of 65 with recurrent breast cancer received either tamoxifen or cyclophosphamide, methotrexate, and fluorouracil (CMF). After progression on tamoxifen, a hormone withdrawal period was required. Because of altered pharmacokinetics with aging, creatinine clearance was used in calculating the dose of CMF. Response rates were 45% on tamoxifen and 38% on CMF, with median durations of 10.4 and 7.9 months, respectively. Survival rates tended to favor tamoxifen as the initial treatment even in estrogen-receptor-negative patients. Additional disease control with hormone withdrawal occurred in 23% of patients, and this benefit was highly correlated with prior hormone response. We conclude that initiation of hormone therapy rather than CMF chemotherapy is justified in almost all situations in elderly patients, and combination chemotherapy, is safe and useful after hormone failure if modified on the basis of renal dysfunction.
AD
PMID3513684

67
PubMed
TIA randomized trial in postmenopausal patients with advanced breast cancer comparing endocrine and cytotoxic therapy given sequentially or in combination. The Australian and New Zealand Breast Cancer Trials Group, Clinical Oncological Society of Australia.
AU
SOJ Clin Oncol. 1986;4(2):186.

A prospective randomized clinical trial was performed in 339 postmenopausal patients with advanced breast cancer. Two single modality treatment sequences, doxorubicin plus cyclophosphamide (AC) followed on failure by tamoxifen (TAM), and TAM followed by AC, were compared with combined modality chemo-endocrine therapy (TAM plus AC). The response rate to initial TAM (22.1%) was inferior to that for AC (45.1%), and for TAM plus AC (51.3%). However, patients randomized to the sequence TAM followed by AC showed a 42.5% overall tumor response to sequential protocol therapy, similar to the 46.9% for those randomized to AC followed by TAM. Furthermore, survival in all three arms was almost identical. Adverse prognostic factors for survival were liver metastases, short disease-free interval, poor performance status, and prior adjuvant chemotherapy. In no subgroup was significantly better survival associated with initial cytotoxic therapy. Endocrine therapy followed on failure by cytotoxics is appropriate for postmenopausal patients with advanced breast cancer.
AD
PMID2868074

Dr_GATOをはじめその他名の医療カテゴリの専門家が質問受付中

医療 についての関連する質問