positive aging, quality living - equal opportunities to ... · distribution of female breast cancer...
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長者乳癌，老有所「醫」 -樂活長者正向面對荷爾蒙受體陽性（HR+）乳癌
新聞發佈會
Positive Aging, Quality Living - Equal Opportunities to Multidisciplinary
Hormone Receptor Positive (HR+) Breast Cancer Treatment Press Conference
2014年11月11日
November 11, 2014
香港大學李嘉誠醫學院 Li Ka Shing Faculty of Medicine
The University of Hong Kong
講者 Speakers
曾詠恆醫生 Dr. Janice Tsang 內科腫瘤專科 Specialist in Medical Oncology
臨床腫瘤學系臨床助理教授 Clinical Assistant Professor
Department of Clinical Oncology
Li Ka Shing Faculty of Medicine, The University of Hong Kong
施俊健醫生 Dr. Henry Sze 臨床腫瘤專科 Specialist in Clinical Oncology
臨床腫瘤學系臨床助理教授 Clinical Assistant Professor
Department of Clinical Oncology
Li Ka Shing Faculty of Medicine, The University of Hong Kong
關兆洸醫生 Dr. Joseph Kwan 內科學系 Clinical Associate Professor
臨床副教授 Department of Medicine
Li Ka Shing Faculty of Medicine, The University of Hong Kong
引言
Introduction
長者日
自1979年以來每年十一月的第三個星期日
Senior Citizens’ Day
-3rd Sunday of every November since 1979
全球乳癌關注月-每年十月
Following Global Breast Cancer Awareness Month
Every October
3
引言
Introduction
• 癌症是一種老化性疾病
• Cancer is an aging disease
乳癌是在上升趨勢
• Breast Cancer is rising on the trend
– low mortality : incidence ratio (2007-2011): 0.17
4
5
香港癌症資料統計中心，2011 Hong Kong Cancer Registry, 2011
2011年按年齡組別分佈的乳腺癌發病及死亡率 Age-specific Incidence & Mortality Rates for Female Breast Cancer in 2011
6
年齡超過65歲之乳腺癌患者:
Invasive BC aged >=65”:
818/3419 = 23.9%
2011年女性乳腺癌按年齡組別及類型之分佈
Distribution of Female Breast Cancer by Age Group & Type in 2011
年齡超過75歲之乳腺癌患者:
Invasive BC aged >= 75:
423/3419 = 12.37%
乳腺癌 - 女性中最常見的癌症
Breast Cancer -The Commonest Female Cancer
香港癌症資料統計中心，2011
Hong Kong Cancer Registry 2011
局部控制：
手術切除原發或轉移腫瘤
放射治療
Loco-regional control: Surgical resection of primary tumor or secondaries
Radiotherapy
治療乳腺癌的重大突破
Breakthroughs in Breast Cancer Management
輔助/新輔助/舒緩治療：
化療
荷爾蒙治療
標靶治療
輔助藥物
Adjuvant Therapy/Neoadjuvant/Palliative:
Chemotherapy
Hormonal therapy
Targeted therapy
Accessory drugs
根據患者和腫瘤特徵的風險評估 Risk assessment based on patient and tumour characteristics
治療乳腺癌的重大突破
Breakthroughs in Breast Cancer Management
乳腺癌的槍靶
Targets for breast cancer
• 2個主要槍靶 – 荷爾蒙受體
– HER-2 受體
• 2 main targets – Hormone receptors
– HER-2 receptors
度身訂造的個人治療
Treatment tailored made to individuals
荷爾蒙受體陽性乳癌… Hormone positive tumours…
• 約佔所有乳腺癌患者的 2/3
• Account for about 2/3 of all breast cancers
• 無論是雌激素受體陽性/孕激素受體陽性或雌激素受體和孕激素受體同時陽性
• Either ER positive/PgR positive or both ER and PgR positive
• 根據腫瘤的免疫組化染色
• Based on immunohistochemical staining of the tumour
11
荷爾蒙受體陽性乳癌… Hormone positive tumours…
• 對荷爾蒙治療敏感
• Responsive to endocrine therapy
• 比荷爾蒙受體陰性乳癌較低侵略性
• Less aggressive than hormone negative tumours
12
Lum A Lum B Basal Her2
claudin low
乳腺癌肖像的改變 Changing Portraits of Breast Cancer
乳腺癌的分子亞型
Molecular Subtypes of Breast Cancer
Sotirious C, Pusztai L. Gene-Expression Signatures in Breast Cancer. N Engl J Med 2009; 360(8):790-800
Luminal B
Luminal A NormBst Basal-like
HER2+/ER- IFN
Perou and Sorlie classification
乳腺癌的不同亞型
Different Subtypes of Breast Cancer
長者腫瘤學
Geriatric Oncology
• 年齡 是在癌症發展中其中一個最強的危險因素
• AGE is one of the strongest risk factors for cancer development
• 人口老齡化是流行病學中一項重大的挑戰
• The aging population presents a major epidemiological challenge
• 長者的癌症和癌症治療是完全不同的…
• Cancer & cancer treatment is different in the elderly…
長者的定義
Defining the Elderly
• “長者”並沒有一個統一的定義
• No universally accepted age cut-off defining “elderly”
• 驅動老化的過程比實足年齡更重要
• Chronological age is less important than biological events in driving the
aging process
• 但是，實足年齡是定義目標人群的簡單和實用的方法
• But chronological age is a simple and practical way to define a target
population
• 世界衛生組織用65歲為限
• WHO uses 65 years old
– 70歲是最常用的下限
– 70 years is the most commonly used cut-off…
高齡化生物學
Biology of Aging
• 幾乎所有年齡相關的變化都可以導致減少器官功能
• Almost all age-related changes lead to reduced organ function
• 高齡化的3個不同的軌跡
• There are 3 different trajectories of aging:
– 帶有病理及殘疾的高齡化
– Aging with pathology & disability
– 帶有輕微殘疾的正常的高齡化
– Normal aging with some disability
– 帶有最小殘疾的成功的高齡化
– Successful aging with minimal disability
• 高齡化是一種異質性的過程
• Aging is a heterogeneous process…
常見的低期望
Common Low Expectations
• 實足年齡是推動高齡化進程中唯一重要的決定性因素
• Chronological age is the sole important determining factor driving the aging
process
• 實足年齡是決定對高齡患者的治療方案的共同的參考
• Chronological age is the common reference to decide treatment plan for elderly
cancer patients
• 高齡患者不能耐受化療或任何抗癌劑
• Elderly cancer patients do not tolerate chemotherapy or any anticancer agent easily\
• 高齡而有多種共病的患者會承受很大的毒性…
• There is much toxicities related to elderly with multiple comorbidities…
高齡癌症患者是不同的…
Elderly cancer patients are different…
• 年齡相關性器官功能的降低
• Age-related reduced organ functions
• 多種共病
• Multiple co-morbidities
• 認知的改變
• Changes in cognition
– 認知障礙症，譫妄
– Dementia, delirium
– 認知障礙症: 65-69歲中佔1%, >90歲中佔41%
– 1% in 65-69 y.o., 41% in>90 y.o. having dementia
• 摔倒
• Falls
• 多重用藥
• Poly-pharmacy
• 抑鬱和焦慮症發病率較高
• Higher prevalence of depression & anxiety
高齡荷爾蒙受體陽性乳癌患者是不同的…
Elderly HR+ BC are different…
• 即使都是乳癌，高齡和年輕患者有不同的表現：
• Different behaviours even for the same primary compared to young age at
presentation:
– 較慢的節奏
– Slow tempo of disease
– 較低侵略性
– Less aggressive
– 2/3荷爾蒙受體陽性
– 2/3 Hormone positive
– 只累及骨骼或軟組織
– Involving bone-only or soft-tissue disease
– 較少高危的內臟轉移
– Less visceral crisis
高齡化對治療決策的影響...
Impact of Aging on treatment decision making…
• 手術 – 徹底性對舒緩性
• Surgery – definitive vs palliative
– 手術及麻醉風險
– Surgical and anaesthetic risk
• 放射治療 – 耐受和毒性
• Radiotherapy – tolerance and toxicities
– 營養不良
– Poor nutrition or malnourished
• 化療
• Chemotherapy
– 調整劑量，減少劑量，量身定制方案
– Dose adjustment, dose reduction, tailored regimen
• 荷爾蒙治療
• Hormonal therapy
• 標靶治療
• Targeted therapy
23
香港乳癌資料庫第6號報告，2014 Hong Kong Breast Cancer Registry Report No. 6, 2014
以確診時年齡及癌症期數分析接受化療的比率 Rates of Chemotherapy by Age Group and Cancer Stage at Diagnosis
24
Hong Kong Breast Cancer Registry Report No. 6, 2014
Rates of Chemotherapy by Age Group and Cancer Stage at Diagnosis
荷爾蒙受體陽性乳癌 斷定乳癌期數及影響範圍
評估乳癌患者HER2、發病年齡及更年期狀況等
大致沒有徵狀 或 沒有生命危險 內臟危機 或 有生命危險
第一線荷爾蒙治療 第一線化療
有效 無效
第二線荷爾蒙治療
第二線化療
惡化
惡化
惡化
惡化
第三線荷爾蒙治療
有效
無效
無效
第三線化療
再進一步治療 或 舒緩治療
荷爾蒙受體陽性乳癌治療
早期 晚期
根治性治療:
手術
輔助治療:
化療
荷爾蒙治療 標靶治療 放射治療 *治療方案根據 腫瘤病理報告特質
HR + Breast Cancer
Determination of stage and extent of disease Assessment of HER2, age and menopausal status at diagnosis etc.
Relatively asymptomatic, or not life threatening
Visceral crisis or life-threatening disease
1st-line hormonal therapy 1st-line chemotherapy
Response No Response
2nd-line hormonal therapy
2nd-line chemotherapy
Progression
Progression
Progression
Progression
3rd-line hormonal therapy
Response
No Response
No Response
3rd-line chemotherapy
Further line of treatment or Supportive Care
Management of HR+ Breast Cancer
EARLY ADVANCED
Definitive
Treatment:
Surgery
Adjunct Treatment:
Chemotherapy
Hormonal Therapy
Targeted Therapy
Radiotherapy
*According to tumour histopathological features
保乳手術與放射治療
27 Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Lancet. 2011 Nov 12;378(9804):1707-16
歲
歲
歲
歲
歲
保乳手術+放射治療較好 保乳手術+放射治療較差
乳腺癌死亡率
保乳手術
保乳手術+放射治療
Breast Conservation Surgery & Radiotherapy
28 Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Lancet. 2011 Nov 12;378(9804):1707-16
臨床試驗結果
29 Hughes et al. J Clin Oncol. 2013 Jul 1;31(19):2382-7.
年齡> 70歲
HR+ I期（T1N0M0）乳房腫瘤切除術後
荷爾蒙治療 + 放射治療
荷爾蒙治療
放射治療能有效減低局部復發的機會
局部無復發生存率
年
Results from Clinical Trial
30 Hughes et al. J Clin Oncol. 2013 Jul 1;31(19):2382-7.
Age > 70 years
HR+ stage I (T1N0M0) with lumpectomy
Hormonal therapy + Radiotherapy
Hormonal therapy alone
Improvement in locoregional
recurrence with the addition of
radiation therapy
Modern Technique
三維適形電腦掃描設計
肺和心臟保護
充分覆蓋目標
現代放療技術
Modern Technique
3D conformal CT planning
Lung and Heart Protection
Adequacy of Target Coverage
Modern Radiotherapy Technique
縮短治療時間
Haviland et al. Lancet Oncol. 2013; 14:1086-94.
五星期 50Gy/25次 對 三星期 40Gy/15次
更方便
安全有效
更佳的外觀
局部復發率
Shorter Treatment Time
Haviland et al. Lancet Oncol. 2013; 14:1086-94.
50Gy/25fr. in 5 weeks vs. 40Gy/15fr. in 3 weeks
More convenient
Safe and effective
Better cosmesis
The Multidisciplinary Team Model for Elderly Cancer Care (MDT Model)
Elderly
Breast Cancer Patients
Medical
Oncologists
Geriatricians
Surgeons
Pathologists
Nurse
Specialists
Clinical Psychologists
Medical
Social Workers
Physiotherapists
Occupational Therapists
Dietitians
Clinical
Oncologists
Life expectancy is increasing
1971-2011年香港人口平均預期壽命 Life Expectancy in HK from 1971-2011
Lif
e ex
pec
tan
cy
根據資料顯示，達至2030年，65歲以上人口可能有50%增長，至於80歲以上的人口增長甚至達至100% By 2030, there could be 50% more people greater than 65 years old, and 100% more people
greater than 80 years old
高齡化社會 Aging Society
高齡化人士最主要之恐懼為健康衰退 Greatest fear in old age is poor health
• 大概三分之一之高齡人士因身體及腦部不健康而引致「殘弱」
• In one-third of older people, unhealthy body and brain results
in frailty
• 癌症 (Cancer)
• 中風 (Stroke)
• 認知障礙症 (Dementia)
• 心臟病 (Heart disease)
• 呼吸系統疾病 (Lung disease)
大多數高齡人士都身體健壯 Many older people are physically fit
大多數高齡人士都在家庭中擔當重要角色 Many have a vital family role
大多數高齡人士都持續進修學習 Many continue to learn
大多數高齡人士都享受良好的生活質素 Many have a good quality of life
幫助高齡人士更加強壯 Helping older people become stronger
• 適量運動及均衡營養有助高齡人士身心靈更加壯健以接受醫學治療
• Exercise and nutrition can make older people stronger for
medical treatments
一般醫學治療目的 Aim of Medical Treatment
• 促進身體及心靈健康 Better physical and psychological well-being
• 提升生活質素 Better good quality of life
• 不論年齡 No matter what age
荷爾蒙受體陽性乳癌 斷定乳癌期數及影響範圍
評估乳癌患者HER2、發病年齡及更年期狀況等
大致沒有徵狀 或 沒有生命危險 內臟危機 或 有生命危險
第一線荷爾蒙治療 第一線化療
有效 無效
第二線荷爾蒙治療
第二線化療
惡化
惡化
惡化
惡化
第三線荷爾蒙治療
有效
無效
無效
第三線化療
再進一步治療 或 舒緩治療
荷爾蒙受體陽性乳癌治療
早期 晚期
根治性治療:
手術
輔助治療:
化療
荷爾蒙治療 標靶治療 放射治療 *治療方案根據 腫瘤病理報告特質
HR + Breast Cancer
Determination of stage and extent of disease Assessment of HER2, age and menopausal status at diagnosis etc.
Relatively asymptomatic, or not life threatening
Visceral crisis or life-threatening disease
1st-line hormonal therapy 1st-line chemotherapy
Response No Response
2nd-line hormonal therapy
2nd-line chemotherapy
Progression
Progression
Progression
Progression
3rd-line hormonal therapy
Response
No Response
No Response
3rd-line chemotherapy
Further line of treatment or Supportive Care
Management of HR+ Breast Cancer
EARLY ADVANCED
Definitive
Treatment:
Surgery
Adjunct Treatment:
Chemotherapy
Hormonal Therapy
Targeted Therapy
Radiotherapy
*According to tumour histopathological features
綜合會診模式治療高齡癌症患者 The Multidisciplinary Team Model for Elderly Cancer Care (MDT Model)
高齡乳癌患者
Elderly Breast Cancer
Patients
內科腫瘤科醫生
Medical
Oncologists 老人科醫生
Geriatricians
外科醫生
Surgeons
病理科醫生
Pathologists
專科護士
Nurse
Specialists 臨床心理
學家
Clinical Psychologists
醫務社工
Medical
Social Workers
物理治療師
Physiotherapists
職業治療師
Occupational Therapists
營養師
Dietitians
臨床腫瘤科醫生
Clinical
Oncologists
答問環節 Q & A Session