Oncology Frontier: Dr. Ollivotto， it may be safe to omit radiotherapy in patients with low risk of local recurrence. Do you have any useful tools of methods to evaluate the local risk reoccurrence in patients after breast conserving surgery?

　　《肿瘤瞭望》：局部复发风险较低的患者是否可省去放疗。您是否有评估保乳手术后局部复发风险的工具或方法？

　　Dr. Ollivotto: There is both clinical and pathologic and evolving new markers. The clinical things that we know like people with the lowest risk of breast recurrence would be age over 60， small tumor like less than 2 cm that is widely excised so the margins are clear by 0.5 cm， and the tumor involves estrogen receptors so positive estrogen receptors， and the patient is on tamoxifen. I would further add that she should not have lobular carcinoma as opposed to ductal cancer. Lobular cancer is much more likely to be diffuse in the breast or extensive in situ disease or the presence adjacent to the tumor of lymphatic or vascularization. The main clinical thing is age over 60 and there is a spectrum of other pathology factors. If you have all of them， it is suggested that the breast recurrence risk is likely less than 5% at 5 years. The study going on in Canada called the LUMINA study and there we are looking at the expression of， in addition to those factors， the patient should be; HER2 negative， ER positive， on tamoxifen， small tumors and widely excised. In addition to that we measure the KI 67， which is a marker for breast cancer. If KI 67 is also then those are patients who are admitted to the cohort and we think that there recurrence risk long term should be very low. If that is the case then avoiding the low recurrence by giving radiation therapy， which will happen， may only help 2 or 3 or 4 women out of 100 treated. If the risk is that small and the patients over 60， then we know local recurrence can give a second chance for the breast cancer to spread. If we allow a local recurrence the breast cancer develops and it has a second chance to metastasize then patients can eventually die of breast cancer. If we keep the difference in local recurrence and the excess of local recurrence to less than 4%， survival at 10 to 15 years down the road would be at most a 1% difference. Many women might say “well， maybe I will not go through radiation therapy at the expense and time and convenience of the side effects if it only makes a 1% or less difference of my chance to live a life 15 years from now”.

　　Ollivotto教授：临床、病理特征以及一些新型标志物都可用于评估接受保乳手术治疗的乳腺癌患者术后局部复发风险。就临床特征而言，年龄大于60岁、肿瘤直径不足2 cm且可距切缘0.5 cm广泛切除、雌激素受体阳性以及接受他莫昔芬治疗者风险均较低。另外，肿瘤最好是导管癌，不要是小叶癌。因为小叶癌更易在胸部弥漫或存在广泛的原位病变或易发生于淋巴或血管附近。预测复发风险的最重要因素是年龄超过60岁以及一系列病理因素。如果患者同时符合上述所有条件，则其术后五年乳腺癌复发风险可能不足5%。加拿大正在开展的LUMINA的研究观察了HER-2阴性、ER阳性、他莫昔芬治疗、小肿瘤、肿瘤广泛切除以及乳腺癌标志物KI 67对未来复发风险的影响。结果发现，如果患者同时KI 67表达则其长期复发风险将会非常低。符合以上条件的100名患者中，术后再进行放疗防复发只能使其中2~4人受益。如果患者的复发风险很小且年龄大于60岁，则局部复发可使乳腺癌有第二次扩散的机会。如果放任乳腺癌局部复发，则有可能出现二次转移，患者最终可能会死于乳腺癌。如果能通过放疗使乳腺癌局部复发风险降低4%，则未来10~15年内的生存率差异最大可达1%。很多乳腺癌患者可能会说“花费那么多金钱和时间，并忍受放疗副作用，仅能使15年生存率提高1%或更少，那我就不愿意放疗。