Eric P. Winer， MD， FASCO，美国Dana-Farber癌症研究所乳腺癌研究Thompson高级研究员、妇女癌症部部长、乳腺肿瘤中心主任，哈佛医学院医学教授。
专家简介：Eric P. Winer， MD， FASCO，美国Dana-Farber癌症研究所乳腺癌研究Thompson高级研究员、妇女癌症部部长、乳腺肿瘤中心主任，哈佛医学院医学教授。圣加仑早期乳腺癌专家共识专家组主席、ASCO指导委员会成员、乳腺癌咨询专家组成员、临床实践指南委员会成员、领导力发展工作组成员、乳腺癌指南建议小组成员。Winer教授的研究组主要致力于通过临床试验开发新药和新治疗方案，提高和改善乳腺癌患者的管理和生活质量。Winer教授同时也是肿瘤学临床试验联盟乳腺癌委员会的联席主席。
Oncology Frontier: Multi-gene molecular assays can provide accurate and reproducible prognostic information， and sometimes predict the response to chemotherapy. However， they are too expensive and depend highly on the techniques. So in the area where multi-gene molecular assays are unavailable， what’s the indication for chemotherapy in patients with luminal A-like type breast cancer?
Dr Winer: I don’t think the answer is to just give everyone chemotherapy. If you have a patient who has an estrogen and progesterone receptor-positive cancer that is not a high-grade cancer (i.e. a low to intermediate grade cancer)， I personally think that it is reasonable to have a conversation with the patient about endocrine therapy alone， assuming she doesn’t have stage III breast cancer. For the patient who has lymph node-negative breast cancer and even selectively for the patient who has one to three positive lymph nodes， it is not unreasonable to think about omitting chemotherapy. However， the more disease a woman has， the more uncomfortable I become at omitting it without further information from one of the multi-gene assays. Personally， I am not a fan of Ki-67. My own sense of this is that the testing is quite variable and unreliable and I don’t think it is something we can necessarily substitute for a multi-gene assay.
Oncology Frontier: Which chemotherapy strategies would you suggest for selected patients with luminal A-like type breast cancer?
Dr Winer:The situation with luminal A-like breast cancer is that the tumors tend not to be terribly chemotherapy responsive. If you are using chemotherapy， you are using it because the patient has a particularly high disease burden and you are trying to not leave any stone unturned in terms of reducing the risk of disease recurrence. In that context， you can use any chemotherapy regimen although in our own institution， the fact is that if we had someone with stage III luminal A-like breast cancer who did not have a strong preference not to receive chemotherapy then we would treat her with chemotherapy and not obtain a multi-gene assay in that setting of stage III disease， and most of the time， we would probably treat her with an anthracycline followed by a taxane.
Winer教授：Luminal A 样乳腺癌的情况是，肿瘤对化疗的应答往往并不强。如果使用化疗，是因为患者有特别高的疾病负担，你千方百计不想错失任何可以减少疾病复发风险的机会而使用化疗。在这种情况下，你可以使用任何化疗方案。我们研究所的情况是，如果有一位Ⅲ期Luminal A样乳腺癌患者，患者本人并不是强烈拒绝化疗，我们就会在未进行多基因检测的情况下，对其实施化疗。而且大多数时候，我们可能会选择蒽环序贯紫杉的方案。
Oncology Frontier: A growing number of studies indicate that to treat different types of patient， different strategies should be taken. That’s called tailoring therapy. For example， there are some investigations on fewer drugs in combination and shorter duration of chemotherapy， like the NSABP-B studies， which got a comparable result with traditional strategy. So the question is， do we really need so many drug combinations and such intensive therapy? What kinds of patients should be considered for such therapy?
Dr Winer:The NSABP B30 study actually demonstrated that AC followed by paclitaxel was better than four cycles of an anthracycline and docetaxel， so it’s a little hard to know which regimens can be used that are tailored for the individual tumor. I do believe that patients who have a lower disease burden and stage I disease， for example， in general don’t need such an extensive chemotherapy regimen. The benefits of the treatment are smaller. The risks of the regimen don’t change because the benefits are smaller. So if I am going to use chemotherapy， I am going to use a better-tolerated regimen. The one situation where we have a fair degree of confidence that we can back away from some of the traditional chemotherapies is in patients with stage I HER2-positive cancers， where we have demonstrated that giving twelve weeks of paclitaxel with a year of trastuzumab gives extraordinary outcomes at least in the relatively short term.
Oncology Frontier: There is no optimal adjunctive chemotherapy for triple-negative breast (TNB) cancer for now. Will you agree that platinum-based therapy should be used in triple-negative breast cancer， at least in some certain situation and in some certain patients?
Dr Winer:As a general rule， platinum shouldn’t be used as an adjuvant therapy for triple-negative breast cancer. The one exception I would give to that is the patient who has a BRCA mutation. In that context， I think we are in a place where we have enough data where one can make the choice to use platinum that is based on pretty solid evidence although not direct evidence. For all other patients with triple-negative breast cancer， we know there is an improvement in pathologic complete response but we do not know that that leads to an improvement in disease-free or overall survival. Until we have those data， I would not encourage the use of platinum in that setting.
Oncology Frontier: On Saturday， the expert panel will discuss and vote for the St. Gallen international consensus. From your perspective， what will be the most important update in the St. Gallen consensus this year?
Dr Winer:I think there are a few updates that will be important. The panel will certainly consider more comprehensively than in the past， the role of ovarian suppression and the role of aromatase inhibitors in premenopausal women. That may be the most far-reaching and important area that the panel chooses to tackle. There will be discussion about anti-HER2 regimens in the adjuvant setting. I don’t think anything has changed too dramatically in the setting of triple-negative breast cancer that will have much impact. Finally， I think there will be some discussion about certain local therapy issues and discussions about acceptable margins. It was raised yesterday that we should begin to think of very low estrogen-positivity as the equivalent of triple-negative disease and whether or not that gets into the discussion remains to be seen， but it is certainly an interesting question.
Oncology Frontier: Tailoring therapy and precision treatment are keywords at St. Gallen 2015. Do you think age is an important factor to design an individualized treatment strategy? What are the key factors that should be considered for very young women and very old women， respectively?
Dr Winer:Age is important， although we have to be careful not to discriminate against older women and make appropriate decisions keeping age in mind. And we have to be careful not to discriminate against younger women in that we tend to over-treat young women if anything. With older women， we have to remember two things. First， there are competing causes of mortality and some of the women who receive treatment will simply not live long enough to see the benefits of that therapy. The second consideration is that they typically have more significant toxicity. If you treat a 75 or 80 year old woman with a course of adjuvant chemotherapy， there is probably no better way than that to make her feel like she is 80 or 85. To what extent that impacts on her negatively in terms of long-term health is less than fully clear. In young women， I think we need to get away from the assumption that all breast cancer in young women is associated with a poor prognosis. While the distribution of tumors in younger women is different than in older women and tend， on average， to be more aggressive tumors， there are cancers in young women that are luminal A-like that are probably best treated with hormonal therapy alone.