ġ඿‫ࢃ੅܈‬༞੩ၷ༹̤̫ͥͅΠρΑΜΒζήġ͈࿪सࠐफ‫ڠ‬എ໦ଢ଼ĲĲĲĶĲ ฒ‫܊‬ġ࠲ ġ໛നġࠉ ġ‫ئ‬तġࢴඵ჊ ġȁఱ‫ޘ‬ġ࿭ဎ ġġġೋ౓ġ‫֚ܔ‬჊ĲĪġġġġĲĪġĳĪĴĪĲĪġġĲĪġ൐‫ނ‬ఱ‫ڠ‬ఱ‫֭ڠ‬࿪‫֓شݪࡄࠏڠ‬࿪ଽॐ‫ڠ‬ȁġġġĳĪġၠ೒‫ڠش‬ఱ‫ڠ‬ġ΍ȜΫΑॲު‫ڠ‬໐ġġġĴĪġ൐‫ނ‬ఱ‫ڠ‬ఱ‫شݪࡄࠏڠ֭֓ڠ‬ġ‫ڠע‬Ʀထཡ༗࠲‫ڠ‬໦࿤࿒എ৽̈́‫ب‬೰㫤㩷 ͉ഢ֊଻඿‫͙͈ͅ܈‬ȁΠρΑΜΒζή ĩ ΧȜΓίΙϋġġĪĩĲĪġΠρΑΜΒζή͈࢘‫ࠑ̞̦́̾͘ض‬௽̳̥͉ͥྚࠨഐ؊̦̜̦ͥȂ ੅ࢃ༞੩ၷ༹̱͈͂̀ঀဥͅ‫̱̀͜۾‬ȁ಍̜́ͥȃ ̷̭́࢘‫ ̦ض‬Ķ ාƦĲı ාƦĲĶ ාƦ֚ġ୆‫پ‬௽ġ࣭ඤ‫΀͈́ٸ‬ΫΟϋΑ̦ಇୟ̱̜̾̾ͥȃ ̱̥̱Ȃ ֓ၷġ̩̞̠͂ ĵ ͈̾Ώ΢ς΂ͅ‫ ̧̿ܖ‬Ŋńņœ ͬࠗॳ̱̹ȃ๯͈௩‫̦ح‬২ٛഎ̈́࿚ఴ͂̈́ͥಎ́֓ၷ঩࡙͈ഐୃ෻ĩĳĪ ఘਹ͉඾ུ૽੫଻໹޳͈ ĶıĮķıŬŨĩĲĶıŮŨ Ψͼͺ໦̞̠͂۷ത̥ͣࡉͥ͂Ȃ ΠρΑΜΒζή͉ࣞ‫̈́ث‬࿪सȁσ ĳ ུ ĬķıŮŨ Ψͼͺσ Ĳ ུ Ī ͬດ੔̱̹̦͂Ȃȁȁȁȁ̷̜͈́ͤࠐफ଻̦‫ه‬ఴ͂̈́ͥȃ ȁȁĶıŬŨ ո‫ئ‬ȁĩĲĶıŮŨ Ψͼͺσ ĳ ུ ĪȂķıĮĸĶŬŨĩĲĶıŮŨĲĪȁ̷̭́Ȃ ດ੔എ̈́‫ڠا‬ၷ༹ਞၭࢃȂ ŉņœłġŴŵŶťźġġͅȁΨͼͺσ Ĵ ུ Ī ͈ાࣣۜ͜ഽ໦ଢ଼̤̞̀ͅ࠿൦̱̹ȃ‫̞̀̿ܖ‬ΠρΑΜΒζή ĩ ੝ٝ ĹŮŨİŬŨġĬġĳ ٝ࿒ոࣛġĩĴĪġ඿‫͈܈‬ಿ‫ܢ‬ထࢃͅ‫̱̀۾‬Ȃ Ķ ා࿒ո͈ࣛठอၚ͉ȁķŮŨİŬŨİĴŸŦŦŬŴĪ ͬ Ĳ ා‫ۼ‬ൎဓ̱̹߲͂๱ൎဓ߲ͬȁĶ ා࿒͈́͘ ıįĶ ෼̱̹͂ȃ๤‫̱ڛ‬Ȃ ŐŷŦųŢŭŭġŴŶųŷŪŷŢŭġĩŐŔĪ ͬͺ;Π΃θঐດ̱̹͂๯ĩĵĪȁ໗ैဥ̜́ͥ૤ࠬ‫ͼࠏۯ‬αϋΠ͈๯ဥ͉‫ܢ‬ఞ౵̦ȁဥ࢘‫ض‬໦ଢ଼࣐̹ͬ̽ȃȁ઀̯̞̹͛ࣉၪ̱̞̞̀̈́ȃˏĪࠫ‫ض‬༹༷ĩĲĪġࡄ‫ݪ‬ΟΎͼϋȁŵŢţŭŦĲĻ ΠρΑΜΒζή࢘‫ࠑض‬௽‫ ͂ۼܢ‬Ŋńņœĩ ௩໦๯ȁȁ๯ဥ࢘‫ض‬໦ଢ଼ ĩŤŰŴŵĮŦŧŧŦŤŵŪŷŦůŦŴŴġŢůŢŭźŴŪŴĻġńņłĪĭġࠫȁဥ࢘‫ض‬๤ Ī‫͉ض‬௩໦๯ဥ࢘‫ض‬๤ ĩŪůŤųŦŮŦůŵŢŭġŤŰŴŵĮŦŧŧŦŤŵŪŷŦůŦŴŴġĩĲĪġΠρΑΜΒζή͈࢘‫̦ض‬Ķා‫ۼ‬௽̩ાࣣ๯ဥųŢŵŪŰĻġŊńņœĪ ́ນ̳ȃ௩໦๯ဥ࢘‫ض‬௩໦࢘‫ض‬Ŋńņœĩ௩໦๯ဥ࢘‫ض‬๤ĪĲįķĳźŝĲĹĺྔİōŚňĩĳĪġచયŰţŴŦųŷŢŵŪŰůŝĹĭĵĹķĭĹĺĸĲĲįķĴ̕ŵųŢŴŵŶŻŶŮŢţ ŝĲĲĭĶĵĹĭĺķķ ŝĴĭıķĳĭıķĺ ĲĴįĳķ̕ȁŉņœĳ ု଻ۛ৪ ĩ ාႢġĶı ध ĭ ఘਹ ĶıĮķıŬŨĪȃĩĳĪġΠρΑΜΒζή͈࢘‫̦ض‬Ĳıා‫ۼ‬௽̩ાࣣ๯ဥĩĴĪġκΟσ௩໦๯ဥ࢘‫ض‬௩໦࢘‫ض‬Ŋńņœĩ௩໦๯ဥ࢘‫ض‬๤ĪĳįĲĸźŝĲĳĶྔİōŚňȁ‫ڠا‬ၷ༹ࢃ͈ࠐً͉Ȃ ζσ΋έκΟσͬै଼̱̀໦ଢ଼ŰţŴŦųŷŢŵŪŰůŝĹĭĵĹķĭĹĺĸĲĲįķĴ̕ŵųŢŴŵŶŻŶŮŢţ ŝĲĲĭĳıĴĭĸĺĺ ŝĳĭĸĲķĭĺıĴ ĲĴįĹı̱̹̕ ĩŧŪŨįĲĪȃ ζσ΋έ΍ͼ·σ͉࠮ౙպ́ Ķı ා‫ࠗۼ‬ĩĴĪġΠρΑΜΒζή͈࢘‫̦ض‬ĲĶා‫ۼ‬௽̩ાࣣ๯ဥķıı ΍ͼ·σ̱̹͂ȃ ȁ௩໦๯ဥ࢘‫ض‬ŰţŴŦųŷŢŵŪŰůŝĹĭĵĹķĭĹĺĸĲĲįķĴ̕ŵųŢŴŵŶŻŶŮŢţ ŝĲıĭĺĳĲĭĸĶı ŝĳĭĵĴĵĭĹĶĴ ĲĵįĲĹź௩໦࢘‫ض‬Ŋńņœĩ௩໦๯ဥ࢘‫ض‬๤ĪĳįĶĶźŝĺķྔİōŚňĩĵĪġΠρΑΜΒζή͈࢘‫̦֚ض‬୆‫پ‬௽̩ાࣣ๯ဥ௩໦๯ဥ࢘‫ض‬ŰţŴŦųŷŢŵŪŰůŝĹĭĵĹķĭĹĺĸĲĲįķĴźŵųŢŴŵŶŻŶŮŢţ ŝĲıĭĳĵķĭĳĺĹ ŝĲĭĸĶĺĭĵıĳ ĲĵįĸĲź௩໦࢘‫ض‬Ŋńņœĩ௩໦๯ဥ࢘‫ض‬๤ĪĴįıĸźŝĶĸྔİōŚňźĻġźŦŢųĭġōŚňĻġŭŪŧŦĮźŦŢųĮŨŢŪůŦťĭġŊńņœĻġŪůŤųŦŮŦůŵŢŭġŤŰŴŵĮŦŧŧŦŤŵŪŷŦůŦŴŴġųŢŵŪŰĩ௩໦๯ဥ࢘‫ض‬๤ĪġŵŢţŭŦĳĻġΠρΑΜΒζή࢘‫ࠑض‬௽‫͂ۼܢ‬ఘਹ·ρΑ͈ழ̵͙ࣣͩͥ͢ͅ Ŋńņœĩ ௩໦๯ဥ࢘‫ض‬๤ Ī ͈་‫ا‬ŸŦŪŨũŵġŤŭŢŴŴŦŧŧŪŤŢŤźġűŦųŪŰťġŰŧŵųŢŴŵŶŻŶŮŢţĩĵĪġΟȜΗſĶıŬŨĶıŬŨſķıŬŨķıŬŨſĸĶŬŨŝĲĶıྔİōŚňŝĲĹĺྔİōŚňŝĳĴĵྔİōŚňĲıġźŦŢųŴ ŝĲııྔİōŚňŝĲĳĶྔİōŚňŝĲĶĹྔİōŚňĲĶġźŦŢųŴŝĸĵྔİōŚňŝĺķྔİōŚňŝĲĳĳྔİōŚňŭŪŧŦŵŪŮŦŝĵıྔİōŚňŝĶĸྔİōŚňŝĸĸྔİōŚňĶġźŦŢųŴȁͺ;Π΃θ͉ ŉņœłġŴŵŶťź ͬဥ̞Ȃ ΋ΑΠ͉৽ͅ ĳııĵࠫაා͈૷ၷ༭ਫതତນ͂࿪‫ܖث‬੔ͬဥ̞̀ೄ୪֓ၷ๯͈͙ͬࣉၪ̱̹ȃĩĶĪġ‫֨ڬ‬ၚȁͺ;Π΃θȂ ΋ΑΠ͂͜ͅාၚ ĴĦ ́‫̹̞֨ڬ‬ȃ ıĦġĮġķĦ ͈ํս́ۜഽ໦ଢ଼࣐̹ͬ̽ȃĩĲĪġා‫ۼ‬૧ܰ඿‫ۛ܈‬৪ͬˍྔ૽Ȃ ̷͈̠̻ˎˌɓ̦ ŉņœȁȁȁု଻̜́ͤȂ ઁ̩̈́͂͜ා‫ ׫ྔˌˌˍۼ‬İ ૽೏‫ح‬എġͅ๯ȁဥ̦อ୆̳ͥ͂ࣉ̢ͦ͊Ȃ ţŶťŨŦŵġŪŮűŢŤŵ ͉ˎˌ‫́׫ؙ‬ġġġġ̜ͥȃġා‫ۼ‬ତ਱‫׫ؙ‬೾ഽ͈֓ၷ๯௩‫̭ͥͦ͘ࡉ̦ح‬ȃġġĩķĪġ૷ၷκΟσ͈୭೰ġȁ‫ڠا‬ၷ༹ࢃ͈૷ၷࠐً͉Ȃ ࣭ඤ ŉņœł ४‫ح‬ঔ୭͈ͺˎĪĩĳĪġΠρΑΜΒζή͈඿‫܈‬ठอဲଷ࢘‫̞̩̦ͣͦ̓ض‬௽ȁϋΉȜΠ಺औ̤͍͢ ŉŰųŵŰţŢŨźŪ ͈ͺσΌςΒθȁͬ४ࣉȁ̩̥̦ະྶ̜̹́ͥ͛Ȃ Ŋńņœĩ ௩໦๯ဥ࢘‫ض‬๤ Ī ͬതȁͅ ŧŪŨįĳ ͈̠͢ͅ୭೰̱̹ȃȁ́ଔ೰̳̭͉ͥ͂ඳ̱̞̦Ȃ Ĵ ා೾ഽ࢘‫̦ض‬঵௽̳ͦȁ͊Ȃ̳͓͈̀ఘਹ·ρΆ Ķıı ྔ‫ ׫‬İȁōŚň ո‫ͥ̈́͂ئ‬ȃĩĴĪġͼΆςΑ͈ ŏŊńņġĩŏŢŵŪŰůŢŭġŊůŴŵŪŵŶŵŦġŧŰųġˤŦŢŭŵũġŢůťġȁġġġ

1yr Trastuzumab or observation,[5 years AI] or [3 years LHRH+TAM + 2 years TAM] for ER positive, follow-up

local recurrence

BCT at primary

mastectonomy at primary

mastectonomychestwall resection
premenopausal>1yr after
LHRH completion

postmenopausal

hormone therapy
unresponsive

hormone therapy
responsive

postmenopausal

hormone therapy
responsiveġńŭŪůŪŤŢŭġņŹŤŦŭŭŦůŤŦĪ ͉́ ĲŒłōŚ ̜̹ͤ ĳ ྔȡ Ĵ ྔεġġġ

metastatic recurrence

hormone therapy
unresponsive

premenopausal

AIT+TAX<1yrMPA
T+CAP

AI

LH-RH+TAM

ġ̦͉ͭ́হၷͤ͢ͅංͣͦͥ ŒłōŚ ͂ ŭŪŧŦĮźŦŢų ̦͕͖ġ൝̱̞̯̭̥͂ͦͥ͂ͣȂ ŏŊńņ ͈Ჷ౵̷͈ͬ͘͘४ચȁȁ̳ͥ͂Ȃȁॳ੄̯̹ͦΠρΑΜΒζή͈ Ŋńņœĩ ࿩ Ĳĺı ྔ

LH-RH+TAM
T+VNB

TAMġϋΡ ĩ ࿩ ĵııĮķıı ྔ‫ ׫‬Ī ̦Ჷ౵͈࿒հ̞͂̈́̽̀ͥȃġġȁ‫ ׫‬Ī ͉๯ဥచ࢘‫ͅض‬࿹̹ͦ౵͂ࣉ̢ͣͦͥȃĩĵĪġŏŊńņ ͉́ Ĳ ා‫ۼ‬ΠρΑΜΒζήൎဓ͈ Ŋńņœ ͬȁȁȁȁġĲĹĭııı εϋΡ İŒłōŚ Ȫ࿩ Ĵķı ྔ‫׫‬ȫ ͂ଔ೰̱̤̀ͤȂobservation
MPAresistance tochemotherapyġĳııķ ා ķ ࠮ͅ੄̯̹ͦ ťųŢŧŵġŨŶŪťŢůŤŦ ͉́Ȃ ੅ࢃ༞

metastatic recurrence
AI: aromatase inhibitor, TAM: tamoxifen, LH-RH: LHRH agonist, MPA: medroxyprogesterone acetate
T: trastuzumab, TAX: paclitacel, VNB: vinorelbine, CAP: capecitabine

palliative

Figure2. Assumed process of breast cancer treatment. The white letters on a dark eclipse backgrounf means
concrete treatment. We abbreviate bone metastasisin this figure but patients with some ogmetatic disease to thebone are treated with bispgosphonateġ੩ၷ༹͈́ঀဥ̦ଔ੻̯̞ͦ̀ͥȃĩĶĪġอນ̯̞̞̩̥͈ͦ̀ͥ̾ œńŕ ུ͂໦ଢ଼ࠫ‫̥ͣض‬Ȃġġġ੅ࢃ༞੩ၷ༹͈́ΠρΑΜΒζή Ĳ ා‫ۼ‬ൎဓ͉Ȃ ခ࢘଻ġƦࠐफ଻͈ၰ࿂̤̞̀ͅ࿹̞ͦ̀ͥ͂ࣉ̢ͣͦͥȃȁŜųŦŧŦųŦůŤŦŞĲĪġőŪŤŤŢųŵĮňŦţũŢųŵġŎŋĭġőųŰŤŵŦųġŎĭġōŦźŭŢůťĮŋŰůŦŴġŃĭġŦŵġŢŭįġŕųŢŴŵŶŻŶŮŢţġŢŧŵŦųġŢťūŶŷŢůŵġŤũŦŮŰŵũŦųŢűźġŪůġŉņœĳĮűŰŴŪŵŪŷŦġţųŦŢŴŵġŤŢůŤŦųįġŏġņůŨŭġŋġŎŦťġġġġġġĳııĶļġĴĶĴĻġĲķĶĺĮĸĳĳĪġŉŰųŵŰţŢŨźŪġňŏįġŕųŦŢŵŮŦůŵġŰŧġţųŦŢŴŵġŤŢůŤŦųįġŏġņůŨŭġŋġŎŦťġĲĺĺĹļġĴĴĺĻġĺĸĵĮĹĵĴĪġņŢųŭźġŃųŦŢŴŵġńŢůŤŦųġŕųŪŢŭŪŴŵŴȧġńŰŭŭŢţŰųŢŵŪŷŦġňųŰŶűġĩņŃńŕńňĪĻġņŧŧŦŤŵŴġŰŧġŤũŦŮŰŵũŦųŢűźġŢůťġũŰųŮŰůŢŭġŵũŦųŢűźġŧŰųġŦŢųŭźġţųŦŢŴŵġŤŢůŤŦųġŰůġġġġġġġġġġġġġġġġġġųŦŤŶųųŦůŤŦġŢůťġĲĶĮźŦŢųġŴŶųŷŪŷŢŭĻġŢůġŰŷŦųŷŪŦŸġŰŧġŵũŦġųŢůťŰŮŪŴŦťġŵųŪŢŭŴįġōŢůŤŦŵġĳııĶļġĴķĶĻġĲķĹĸĮĸĲĸ