绝经后乳腺癌患者内分泌治疗策略课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,绝经后乳腺癌患者内分泌治疗策略,绝经后乳腺癌患者内分泌治疗策略,辅助内分泌治疗的药物,*,无论是否化疗、年龄、绝经状况或淋巴结状况,他莫昔芬,(Tamoxifen),芳香化酶抑制剂,(Aromatase Inhibitors),年复发率,39%*,年死亡率,31%*,阿那曲唑,来曲唑,依西美坦,辅助内分泌治疗的药物* 无论是否化疗、年龄、绝经状况或淋巴结,Recurrence (,复发,),：最具价值的指标,评估“复发”的临床意义,初始局部或系统治疗后应采取何种治疗以及维持期,分类,任何复发,孤立性局部复发,孤立性对侧复发,远处复发,任何远处复发,Saphner T, et al. J Clin Oncol 1996; 14:2738-2746.,Buzdar A, et al. ASCO 2008 abstract 552.,随访时复发率高,随访期内应给予药物治疗,某时间点后复发率,很低甚至无复发,该时间点后不宜给予其他治疗,Recurrence (复发)：最具价值的指标评估“复发”的,乳腺癌的复发高峰出现在术后,1-3,年,Saphner T, et al. J Clin Oncol 1996; 14:2738-2746.,0,5,10,15,20,25,0.5,1.5,2.5,3.5,4.5,5.5,6.5,7.5,8.5,9.5,10.5,时间,(,年,),各,年,度,的,复,发,风,险,比,合计,阳性淋巴结,0,阳性淋巴结,1-3,阳性淋巴结 ,4,肿瘤直径,(3 cm),ER +ve,ER -ve,绝经前,绝经后,为了最大程度地降低复发的危险性，,重要的是在复发风险最高的时期使用最有效的治疗方法,乳腺癌的复发高峰出现在术后1-3年Saphner T, et,问题一起始策略,(Upfront Strategy),：,AI vs. TAM,1,问题一起始策略(Upfront Strategy)：AI,荟萃分析：起始,AI,较,TAM,显著降低复发率,Ingel J, et al. Presented at 31th SABCS 2008.,他莫昔芬,AI,治疗,5,年,R,直接比较,(N=9856),相关研究：,ATAC/BIG1-98,年复发风险比,(AI:TAM),2P,任何复发,0.77,0.00001,孤立性局部复发,0.70,0.003,孤立性对侧复发,0.59,0.0009,远处复发,0.84,0.009,任何远处复发,0.82,0.002,荟萃分析：起始AI较TAM显著降低复发率Ingel J, e,荟萃分析：起始,AI,的获益在治疗早期更显著,Ingel J, et al. Presented at 31th SABCS 2008.,荟萃分析：起始AI的获益在治疗早期更显著Ingel J, e,起始策略,(Upfront Strategy),：,AI vs. TAM,复发率显著低于他莫昔芬,5,年绝对获益：,2.9%,8,年绝对获益：,3.9%,孤立性局部或对侧复发风险的获益更显著,孤立性局部复发：,HR=0.70,；,p=0.003,孤立性对侧复发：,HR=0.59,；,p=0.0009,起始,AI,治疗早期的获益更显著,Ingel J, et al. Presented at 31th SABCS 2008.,起始策略 (Upfront Strategy)：AI vs.,问题二所有的,AI,都适合起始治疗吗？,2,问题二所有的AI都适合起始治疗吗？2,TEAM,研究,Jones SE, et al. Presented at 31th SACBS 2008.,Rea D, et al. presented at 32th SACBS 2009.,2.75,年：起始,T vs. E,1,5.1,年：换药,T,E vs.,起始,E,2,确诊并充分,接受初始治疗的,早期乳腺癌,他莫昔芬,依西美坦,依西美坦,入组,N=9775,绝经后,ER+,妇女,总计,5,年治疗,2.75,年时的,DFS,5,年时的,DFS,IES,研究阳性结果,主要终点,R,TEAM研究Jones SE, et al. Present,2.75,年：起始,E,较起始,T,未显著延长,DFS (ITT),随访时间,(,年,),HR=0.89,95%CI: 0.77-1.03P=0.12,T,E,DFS,事件概率,0,0.02,0.04,0.06,0.08,0.10,0,0.5,1.0,1.5,2.0,2.5,RFS,HR=0.85 (0.72-1.00),P=0.05,TTDR,HR=0.81 (0.67-0.98),P 2 cm,(35%,vs,. 26%),Mouridsen H et al.,N Engl J Med,2009;361:766-76.,BIG1-98中选择性换药的影响Mouridsen H et,可能影响,BIG1-98,研究的因素,随访,26,月,(2005,年,),时，来曲唑优效的结果使后续他莫昔芬组的设计从盲性变为开放性,619 (25.2%),的患者选择性地交叉进入来曲唑组,绝大部分在治疗的,3-5,年间,交叉进入来曲唑组的患者中位治疗持续,18,月,以上现象使他莫昔芬组的比较变得复杂,Mouridsen H, et al. Presented at 31th SABCS 2008.,可能影响BIG1-98研究的因素随访26月(2005年)时，,BIG 1-98,：小结,起始来曲唑较起始他莫昔芬,显著延长,DFS,延长,TTDR,，但优势在缩小,延长,OS,，但无显著性优势,未报道对侧乳腺癌事件和,TTR,Mouridsen H, et al. Presented at 31th SABCS 2008.,BIG 1-98：小结Mouridsen H, et al,ATAC,：起始阿那曲唑,vs.,起始他莫昔芬,手术,放疗,化疗,(20%),阿那曲唑,1mg po.qd,+,安慰剂,(n=3125),他莫昔芬,20mg po.qd+,安慰剂,(n=3116),1996.7,月,-2000.3,月,21,个国家,381,个中心,共入组,9366,例患者,绝经后浸润性乳腺癌患者,R,主要研究终点,无病生存期,安全性,/,耐受性,次要研究终点,对侧乳腺癌的发生率,至复发,/,远处复发时间,生存期,随访,The ATAC Trialists Group. Lancet 2002; 359:2131-2139.,The ATAC Trialists Group, Lancet Oncol 2004.,The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC：起始阿那曲唑 vs. 起始他莫昔芬手术 放疗,ATAC100,月：瑞宁得显著延长,DFS,30,25,20,15,10,5,0,13.9%,16.4%,25.8%,29.9%,0,1,2,3,4,5,6,7,8,9,他莫昔芬,阿那曲唑,HR=0.85,95%CI=0.76-0.94,P=0.003,(,年,),2.5%,4.1%,DFS,事件概率,(%),治疗后随访期,5,年治疗期内,绝对获益,ATAC100月：瑞宁得显著延长DFS30252015105,ATAC100,月：瑞宁得显著降低复发风险,(TTR),30,25,20,15,10,5,0,0,1,2,3,4,5,6,7,8,9,12.5%,17.0%,21.8%,时间,(,年,),9.7%,2.8%,4.8%,绝对获益,他莫昔芬,阿那曲唑,治疗期间,治疗后的随访期,HR = 0.76,，,95% CI 0.67-0.87,，,P = 0.0001,HR+,患者,(%),The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC100月：瑞宁得显著降低复发风险 (TTR) 302,ATAC100,月：瑞宁得显著降低远处复发风险,(TTDR),HR=0.84,，,95% CI 0.72-0.97,，,P = 0.022,30,25,20,15,10,5,0,0,1,2,3,4,5,6,7,8,9,7.8%,9.1%,13.2%,15.6%,随访时间,(,年,),绝对获益,1.3%,2.4%,他莫昔芬,瑞宁得,治疗期间,治疗后的随访期,HR+,患者,(%),The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC100月：瑞宁得显著降低远处复发风险 (TTDR),ATAC100,月：瑞宁得显著对侧乳腺癌事件风险,5,4,3,2,1,0,0,1,2,3,4,5,6,7,8,9,1.0%,1.8%,2.5%,4.2%,绝对获益,0.8%,1.7%,治疗期间,治疗后的随访期,他莫昔芬,瑞宁得,HR=0.60,，,95% CI 0.42-0.85,，,P=0.004,HR+,患者,(%),时间,(,年,),The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC100月：瑞宁得显著对侧乳腺癌事件风险5432100,BIG1-98,研究：来曲唑降低远处复发风险,(TTDR),的优势逐渐缩小,TTDR,风险的降低,BIG1-98,26,个月,1,BIG1-98,51,个月,2,BIG1-98,76,个月,3,27%,P=0.001,19%,15%,P=0.03,P=0.05,The BIG 1-98 Collaborative Group*N Engl J Med 2005; 353:2747-2757.,Coates et al, J Clin Oncol 2007; 25:486.,Mouridsen H et al, Oral presentation at 31th SABCS 2008.,BIG1-98研究：来曲唑降低远处复发风险(TTDR)的优,ATAC,：阿那曲唑持久稳定降低,TTDR,风险,TTDR,风险的降低,ATAC,68,个月,1,ATAC,100,个月,2,16%,P=0.06,16%,P=0.022,The ATAC Trialists Group, Lancet Oncol 2004.,The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC：阿那曲唑持久稳定降低TTDR风险TTDR风险的降低,ATAC 100,月,vs. BIG1-98 76,月,*,随访,51,个月时的结果,*,p=0.05,The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,Mouridsen H, et al. Presented at 31th SABCS 2008.,The BIG 1-98 Collaborative Group*N Engl J Med 2005; 353:2747-2757.,ATAC,100,月,BIG 1-98,76,月,复发,远处复发,对侧乳腺癌事件,*,无报告,*,风险下降,风险下降,ATAC 100月 vs. BIG1-98 76月* 随访5,ATAC/BIG1-98,：其他疗效终点指标,ATAC,100,月,1,BIG1-98,76,月,2,OS,报告,报告,TTR,报告,未报告,TTDR,报告,报告,对侧乳腺癌事件,报告,未报告,ATAC Group, Lancet Oncol 2008; 9:45-53.,Mouridsen H, et al. Oral presentation at 31th SABCS 2008.,ATAC/BIG1-98：其他疗效终点指标ATACBIG1-,小结：所有的,AI,都适合起始治疗吗？,TEAM,研究,33,月：起始依西美坦不优于起始他莫昔芬,(DFS),5.1,年：起始依西美坦不优于他莫昔芬序贯依西美坦,(DFS),依西美坦作为起始,AI,的地位尚有待考量,BIG1-98,研究,76,月：起始来曲唑较起始他莫昔芬显著延长,DFS,76,月：未报道,TTR,及对侧乳腺癌事件的数据,随着随访时间的延长，起始来曲唑的获益不断缩小,(TTDR), 延续效应不强,小结：所有的AI都适合起始治疗吗？TEAM研究,小结：所有的,AI,都适合起始治疗吗？,ATAC,研究,100,月,起始阿那曲唑,DFS,显著长于起始他莫昔芬,第一个提供了长达,9,年完整随访数据的,AI,唯一提供了显著降低乳腺癌各种复发风险的,AI,明显降低复发高峰期内各种复发风险，且具延续效应,两组间治疗没有交叉，数据质量更高、更完整,小结：所有的AI都适合起始治疗吗？ATAC研究 100月,问题三初始接受,TAM,治疗的患者能否改用,AI,？,3,问题三初始接受TAM治疗的患者能否改用AI？3,荟萃分析：序贯,AI,较,5YTAM,显著降低复发率,Ingel J, et al. Presented at 31th SABCS 2008.,年复发风险比,(AI:TAM),2P,任何复发,0.71,0.00001,孤立性局部复发,0.60,0.002,孤立性对侧复发,0.65,0.03,远处复发,0.76,0.001,任何远处复发,0.77,0.0009,他莫昔芬,AI,治疗,2-3,年,他莫昔芬,治疗,2-3,年,R,序贯比较,相关研究：,GABG/ARNO, IES/BIG2-98, ABSCG 8,荟萃分析：序贯AI较5YTAM显著降低复发率Ingel J,荟萃分析：序贯策略的获益在治疗早期更显著,Ingel J, et al. Presented at 31th SABCS 2008.,荟萃分析：序贯策略的获益在治疗早期更显著Ingel J, e,ABCSG 8,：研究设计,随,机,分,组,他莫昔芬,20mg (5,年,),他莫昔芬,20mg (2,年,),阿那曲唑,1mg (3,年,),换药分析,序贯分析,初始,手术,主要终点,RFS*,次要终点,OS,安全性,*,包括局部和远处复发、对侧乳腺癌事件、非复发死亡,Jakesz R, et al. Presented at 31th SABCS.,ABCSG 8：研究设计随他莫昔芬他莫昔芬阿那曲唑换药分析序,ABCSG 8,：研究结论与启示,序贯治疗样本,(N=2922),起始他莫昔芬,2,年后改为阿那曲唑可显著延长,RFS,RFS,事件降低,21% (p=0.038),起始他莫昔芬,2,年后改用阿那曲唑可显著延长,OS,死亡事件降低,23% (p=0.025),Jakesz R, et al. Presented at 31th SABCS.,ABCSG 8：研究结论与启示序贯治疗样本 (N=2922),IES Trial: Design,Postmenopausal women with ER+/unknown primary breast cancer,Diagnosis,Start of study,Total 5 yrs ofendocrine therapy,June 2009 dataset = 91-mo median follow-up (from randomization) = 32296 women-yrs of follow-up available,Tamoxifen(2-3 yrs),Tamoxifen,(2-3 yrs),Posttreatmentfollow-up,Exemestane,(2-3 yrs),RA,N,D,O,M,I,Z,E,Bliss JM, et al. SABCS 2009. Abstract 12.,IES Trial: DesignPostmenopausa,DFS: ER+/Unknown,End of treatment,100,90,80,70,60,50,40,30,20,10,0,0,1,2,3,4,5,6,7,8,9,Yr From Randomization,Women Surviving , Alive and Disease Free (%),HR: 0.82 (95% CI: 0.73-0.92;,P,= .0009),Absolute differenceat 5 yrs = 3.0%(95% CI: 1.3-4.6),Absolute differenceat 8 yrs = 4.4%(95% CI: 1.8-7.2),Exemestane,Tamoxifen,E = 530/2294,T = 622/2305,Events/Patients at Risk, n,E,T,0/2294,0/2305,55/2193,81/2193,59/2124,101/2077,80/2017,98/1948,70/1915,69/1847,67/1810,65/1745,61/1662,70/1596,51/1333,65/1244,53/758,44/676,27+7*/267,22+7*/255,Bliss JM, et al. SABCS 2009. Abstract 12.,DFS: ER+/UnknownEnd of treatme,治疗结束,0 1,2,3,4,5,6,7,8,9,他莫昔芬,阿诺新,存活患者,(%),随机后,(,年,),91,个月总生存,(OS): ER+/,不明,绝对差异,5,年,= 1.4%,(95%CI: 0.1-2.5),HR=0.86 (95%CI:0.75-0.99);,p=0.04,绝对差异,8,年,= 2.4%,(95%CI: 0.1-4.8),E=352/2294,T=405/2305,10,20,30,40,50,60,70,80,90,100,治疗结束0 1,小结：初始接受,TAM,治疗的患者能否改用,AI,？,荟萃分析显示，已接受初始他莫昔芬治疗的患者改用,AI,治疗后可显著降低各种复发风险,ABCSG 8,：唯一证实,AI,序贯他莫昔芬治疗与他莫昔芬相比能同时显著延长,RFS,和,OS,的前瞻性、大样本临床研究,已接受初始他莫昔芬治疗的患者应选择阿那曲唑序贯治疗,小结：初始接受TAM治疗的患者能否改用AI？,影响辅助内分泌药物选择的因素,疗效,安全性,影响辅助内分泌药物选择的因素疗效安全性,TEAM,：心血管疾病,T,E,(4814),E,(4852),中位随访,5.1,年,n,%,n,%,P,值*,心律失常,133,2.8%,170,3.5%,0.042,心力衰竭,36,0.7%,55,1.1%,0.063,心肌缺血,/,梗塞,60,1.2%,77,1.6%,0.183,脑血管局部缺血,35,0.7%,51,1.1%,0.112,其他动脉血栓形成,14,0.3%,12,0.2%,0.680,栓塞,43,0.9%,45,0.9%,0.944,静脉血栓形成,97,2.0%,45,0.9%,0.001,高血压,215,4.5%,293,6.0%,0.001,Rea D et al. presented at 2009 SACBS.,*,p,值,0.01,时有显著统计学差异,TEAM：心血管疾病TE(4814)E(4852)中位随访,TEAM,：肌肉和骨骼事件,T,E,(4814),E,(4852),中位随访,5.1,年,n,%,n,%,P,值*,骨折,170,3.5%,249,5.1%,0.001,骨质疏松,259,5.4%,478,9.9%,0.001,关节痛,961,20.0%,1140,23.5%,0.001,腕管综合征,/,其他神经压迫症,126,2.6%,166,3.4%,0.024,肌肉痛性痉挛,/,病症,302,6.3%,188,3.9%,0.001,Rea D et al. presented at 2009 SACBS.,*,p,值,0.01,时有显著统计学差异,TEAM：肌肉和骨骼事件TE(4814)E(4852)中位,BIG 1-98,：心血管不良事件,(1),中位随访,51,月,任何级别,来曲唑,他莫昔芬,P,CVA/TIA,1.4%,1.4%,0.90,血栓事件,2.0%,3.8%,0.001,心脏事件,5.5%,5.0%,0.48,缺血性心脏疾病,2.2%,1.7%,0.21,心衰,1.0%,0.6%,0.14,其他心血管事件,0.8%,0.2%,0.014,高脂血症,50.6,24.6%,0.001,Coates AS, et al. J Clin Oncol 2007; 25:486.,BIG 1-98：心血管不良事件 (1)中位随访51月来曲唑,BIG 1-98,：心血管不良事件,(2),中位随访51月,3-5,级,来曲唑,他莫昔芬,P,所有心血管事件,2.4%,1.4%,0.001,缺血性心脏疾病,1.1%,0.7%,0.06,心衰,0.7%,0.3%,0.04,高血压,1.4%,1.2%,0.38,CVA/TIA,1.2%,1.2%,0.99,血栓,0.9%,2.3%,0.001,Mouridsen H et al, J Clin Oncol 2007; 25.,BIG 1-98：心血管不良事件 (2)中位随访51月来曲唑,BIG 1-98,：其他不良事件,中位随访51月,任何级别,来曲唑,他莫昔芬,P,阴道出血,3.8%,8.3%,0.001,恶心,9.9%,9.4%,0.63,呕吐,3.0%,3.1%,0.87,潮红,32.8%,37.4%,0.001,夜间盗汗,14.2%,17.0%,0.007,骨折,8.6%,5.8%,0.001,关节痛,20.0%,13.5%,0.001,肌肉痛,7.1%,6.1%,0.19,Coates AS, et al. J Clin Oncol 2007; 25:486.,BIG 1-98：其他不良事件中位随访51月来曲唑他莫昔芬P,ATAC,研究：不良事件发生率,治疗期间,治疗后的随访期内,中位随访,100,月,阿那曲唑,他莫昔芬,阿那曲唑,他莫昔芬,随访妇女人年数,12781,12331,9351,9448,所有,SAE,8.25%,9.12%,3.81%,3.59%,治疗相关,SAE,1.20%,2.30%,0.52%,0.60%,子宫内膜癌,0.03%,0.10%,0.01%,0.13%,心肌梗塞,0.27%,0.27%,0.28%,0.30%,脑血管意外,0.16%,0.28%,0.24%,0.21%,骨折发作,2.93%,1.90%,1.56%,1.51%,The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,ATAC研究：不良事件发生率治疗期间治疗后的随访期内中位随访,AI,的心血管不良事件发生率,ATAC (,随访,68,个月,),1,瑞宁得,他莫昔芬,P,值,缺血性心血管事件,4.1%,3.4%,0.1,静脉血栓事件,2.8%,4.5%,0.0004,深静脉血栓事件,1.6%,2.4%,0.02,BIG 1-98 (,随访,51,个月,),2,来曲唑,他莫昔芬,P,值,3-5,级心脏事件,3%,1.4%,0.001,3-5,级其他心血管事件*,0.8%,0.2%,0.014,TEAM (,随访,5.1,年,),3,依西美坦,他莫昔芬,P,值,高血压,6.0%,4.5%,0.001,*包括动脉瘤，动脉瘤破裂，主动脉扩张，动脉狭窄，动脉硬化，动脉粥样硬化，高血压血管病变，间歇性跛行,1. ATAC Trialists Group. Lancet published online December 8, 2004.,2.,Coates AS et al. J Clin Oncol 2007,.,3. Rea D et al. presented at 2009 SACBS.,AI的心血管不良事件发生率ATAC (随访68个月)1瑞宁得,瑞宁得：唯一证实脑中风发生率明显少于他莫昔芬的,AI,1. ATAC Trialists Group. Lancet published online December 8, 2004. 2.,Coates AS et al. J Clin Oncol 2007.,3. IES Group. Lancet published online February 13, 2007.,ATAC (,随访,68,个月,),1,瑞宁得,他莫昔芬,P,值,脑中风发生率,2.0%,2.8%,0.03,BIG 1-98 (,随访,51,个月,),2,来曲唑,他莫昔芬,P,值,脑中风发生率,1.4%,1.4%,0.9,IES (,随访,56,个月,),3,依西美坦,他莫昔芬,P,值,脑中风发生率,2.5%,2.4%,NR,瑞宁得：唯一证实脑中风发生率明显少于他莫昔芬的AI1. A,阿那曲唑：疗效持久，毒性未持续,The ATAC Trialists Group, Lancet Oncol 2008; 9:45-53.,9,骨折率,时间,(,年,),年骨折率,(%),0,1,2,3,4,5,6,7,8,0,2,3,4,1,30,25,20,15,10,到肿瘤复发时间,复发率,(%),5,0,0,1,2,3,4,5,6,7,8,9,时间,(,年,),+4.8%,他莫昔芬,阿那曲唑,+2.5%,疗效,延续效应,毒性,无延续效应,阿那曲唑：疗效持久，毒性未持续The ATAC Triali,AI,的安全性：小结,起始依西美坦与他莫昔芬序贯依西美坦相比,序贯组妇科不良反应以及潮红、血栓事件发生率明显增加,起始依西美坦高血压发生率明显增加,起始来曲唑相比起始他莫昔芬,3-5,级心血管事件发生率显著高于他莫昔芬,出现更多治疗相关的严重不良反应,因不良反应而退出研究的患者比例更高,起始阿那曲唑相比起始他莫昔芬,心血管事件发生率与他莫昔芬相似,治疗相关的严重不良反应更少,因不良反应而退出研究的患者比例更低,AI的安全性：小结起始依西美坦与他莫昔芬序贯依西美坦相比,绝经后,ER+,早期乳腺癌患者芳香化酶抑制剂治疗的选择策略,结论,绝经后ER+早期乳腺癌患者芳香化酶抑制剂治疗的选择策略,结论,(1),荟萃分析证实，起始,AI,的疗效显著优于起始他莫昔芬,三个,AI,不尽相同,依西美坦,的,TEAM,研究结果阴性，作为起始,AI,的地位尚有待考量；但,IES031,换药试验,91,个月有满意的结果。,来曲唑,可明显降低早期复发风险和远处复发风险。,阿那曲唑,DFS,显著长于起始他莫昔芬,第一个提供了长达,9,年完整随访数据的,AI,唯一提供数据显示明显降低乳腺癌,各种复发风险,的,AI,明显降低术后复发高峰期内各种复发风险并具延续效应,拥有数据的质量更高、更完整,结论 (1)荟萃分析证实，起始AI的疗效显著优于起始他莫昔芬,结论,(2),荟萃分析证实，起始接受他莫昔芬治疗,2,年的,ER+,患者，换用,AIs,可显著延长,RFS,和,OS,ABCSG 8,是目前能够证实他莫昔芬序贯,AI,治疗与他莫昔芬相比能同时显著延长,RFS,和,OS,的前瞻性、大样本临床研究,相比其他,AI,，阿那曲唑更少出现治疗相关严重不良事件，因不良事件而退出研究的患者更少,结论 (2),绝经后,ER+,早期乳腺癌患者芳香化酶抑制剂治疗的选择策略, NCCN,中国版（,2009,）,绝经后ER+早期乳腺癌患者芳香化酶抑制剂治疗的选择策略,绝经后乳腺癌患者内分泌治疗策略课件,THE END,谢谢,THE END谢谢,