Современные подходы к неоадъювантной лекарственной терапии первично операбельного HER2-положительного рака молочной железы

Рак молочной железы в настоящее время занимает первое место в структуре онкологической заболеваемости женского населения во всем мире. Примерно у 15–20 % больных РМЖ наблюдается гиперэкспрессия и/или амплификация рецептора эпидермального фактора роста человека 2 типа (HER2), что обуславливает агрессивное биологическое поведение опухоли и сопряжено с плохим прогнозом. Направленные на HER2 таргетные препараты значительно улучшили прогноз пациентов с HER2-позитивным раком молочной железы. Начиная с самых ранних стадий (T2 и/или N+) пациентам необходимо проведение неоадъювантной лекарственной терапии, которая позволяет непосредственно оценить эффективность лечения, повышает шансы выполнения органосохраняющей операции, а также помогает адаптировать постнеоадъювантную терапию. Схемы химиотерапии на основе антрациклинов исторически были первым вариантом лечения HER2-позитивного РМЖ, поскольку статус HER2 является предиктором эффективности антрациклинов. Однако разработка новых агентов и, как результат, появление новых комбинаций с несколькими анти-HER2-агентами предоставили возможность изучения безантрациклиновых схем, направленных на уменьшение нежелательных явлений и улучшение качества жизни пациентов. Результаты исследования BCIRG-006 по изучению адъювантного применения таких режимов и, позднее, неоадъювантного назначения в протоколе TRAIN-2 ознаменовали поворотный момент в использовании безантрациклиновых схем. Одним из важных открытых вопросов является целесообразность добавления карбоплатина, так как прямые сравнения неантрациклиновых комбинаций с карбоплатином или без него отсутствуют. В настоящее время имеются убедительные доказательства влияния достижения полного патоморфологического ответа (pCR) после неоадъювантного этапа лечения на долгосрочные онкологические результаты. Крайне перспективными являются разработка и валидизация возможных биомаркеров, прогнозирующих достижение pCR.

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