NCCN                                  ®                                                                                   ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 ...
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Mama
Upcoming SlideShare
Loading in...5
×

Mama

7,027

Published on

Published in: Health & Medicine
1 Comment
2 Likes
Statistics
Notes
  • This is not the latest update. Check website for latest guidelines. Currently it is Version 3.2012 (in Oct 2012)
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
7,027
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
112
Comments
1
Likes
2
Embeds 0
No embeds

No notes for slide

Mama

  1. 1. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion ® NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Breast Cancer Version 1.2012 NCCN.org NCCN Guidelines for PatientsTM available at www.nccn.com Continue ® ®Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .
  2. 2. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Panel Members Breast Cancer Table of Contents Breast Cancer Staging, Discussion * Robert W. Carlson, MD/Chair † William J. Gradishar, MD ‡ Elizabeth C. Reed, MD † x Stanford Cancer Institute Robert H. Lurie Comprehensive Cancer UNMC Eppley Cancer Center at The Center of Northwestern University Nebraska Medical Center D. Craig Allred, MD¹ Siteman Cancer Center at Barnes-Jewish Daniel F. Hayes, MD † Mary Lou Smith, JD, MBA ¥ Hospital and Washington University School of University of Michigan Comprehensive Research Advocacy Network Medicine Cancer Center Hatem Soliman, MD Benjamin O. Anderson, MD ¶ Clifford A. Hudis, MD † H. Lee Moffitt Cancer Center & Research Fred Hutchinson Cancer Research Memorial Sloan-Kettering Cancer Center Institute Center/Seattle Cancer Care Alliance Steven Jay Isakoff, MD, PhD † George Somlo, MD ‡ x Harold J. Burstein, MD, PhD † Massachusetts General Cancer Hospital City of Hope Comprehensive Cancer Center Dana-Farber/Brigham and Womens Cancer Center Britt-Marie Ljung, MD ¹ Richard l. Theriault, DO UCSF Helen Diller Family The University of Texas MD Anderson Stephen B. Edge, MD ¶ Comprehensive Cancer Center Cancer Center Roswell Park Cancer Institute David A. Mankoff, MD, PhD f John H. Ward, MD ‡ William B. Farrar, MD ¶ Fred Hutchinson Cancer Research Huntsman Cancer Institute at the University The Ohio State University Comprehensive Center/Seattle Cancer Care Alliance of Utah Cancer Center - James Cancer Hospital and Solove Research Institute P. Kelly Marcom, MD † Antonio C. Wolff, MD † Duke Cancer Institute The Sidney Kimmel Comprehensive Cancer Andres Forero, MD ‡ Center at Johns Hopkins University University of Alabama at Birmingham Ingrid A. Mayer, MD † Comprehensive Cancer Center Vanderbilt-Ingram Cancer Center Richard Zellars, MD § The Sidney Kimmel Comprehensive Cancer Sharon Hermes Giordano, MD MPH † Beryl McCormick, MD § Center at Johns Hopkins University The University of Texas MD Anderson Cancer Memorial Sloan-Kettering Cancer Center Center Lori J. Pierce, MD § Lori J. Goldstein, MD † University of Michigan Comprehensive Fox Chase Cancer Center Cancer Center † Medical Oncology § Radiation Oncology Continue ‡ Hematology/Oncology f Nuclear medicine NCCN Staff ¶ Surgical Oncology x Bone Marrow Transplantation ¹ Pathology ¥ Patient Advocacy Rashmi Kumar, PhD Dorothy A. Shead, MS Ÿ Reconstructive Surgery * Writing Committee Member ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .
  3. 3. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Table of Contents Breast Cancer Table of Contents Breast Cancer Staging, Discussion NCCN Breast Cancer Panel Members Invasive Breast Cancer (continued) Summary of Guidelines Updates · Fertility and Birth Control After Adjuvant Breast Clinical Trials: The NCCN Noninvasive Breast Cancer Cancer (BINV-C) believes that the best management · Lobular Carcinoma In Situ (LCIS-1) · Surgical Axillary Staging - Stage l, llA , for any cancer patient is in a clinical · Ductal Carcinoma In Situ (DCIS-1) and llB (BINV-D) trial. Participation in clinical trials is · Axillary Lymph Node Staging (BINV-E) especially encouraged. Invasive Breast Cancer · Margin Status in Infiltrating Carcinoma (BINV-F) To find clinical trials online at NCCN · Clinical Stage, Workup (BINV-1) · Special Considerations to Breast-Conserving member institutions, click here: · Locoregional Treatment of Clinical Stage l, llA, or llB Disease or T3,N1,M0 (BINV-2) Therapy Requiring Radiation Therapy (BINV-G) nccn.org/clinical_trials/physician.html · Principles of Breast Reconstruction Following · Systemic Adjuvant Treatment (BINV-4) NCCN Categories of Evidence and Mastectomy (BINV-H) Consensus: All recommendations · Preoperative Chemotherapy Guideline · Principles of Radiation Therapy (BINV-I) are Category 2A unless otherwise = Clinical Stage llA, llB,and IIIA T3,N1,M0 Workup (BINV-10) · Adjuvant Endocrine Therapy (BINV-J) specified. = Axillary Evaluation (BINV-11) · Adjuvant Chemotherapy (BINV-K) See NCCN Categories of Evidence = Clinical Stage lllA, lllB, IIIA and Stage IV, · Definition of Menopause (BINV-L) and Consensus Workup (BINV-14) · Principles of Monitoring Metastatic Disease = Preoperative Chemotherapy, Locoregional (BINV-M) Treatment, Adjuvant Treatment (BINV-15) · Subsequent Endocrine Therapy (BINV-N) · Surveillance/Follow-Up, Recurrence Workup or · Preferred Chemotherapy Regimens for Initial Workup for Stage lV Disease (BINV-16) Recurrent or Metastatic Breast Cancer (BINV-O) · Treatment of Recurrence/Stage IV Disease Special Considerations (BINV-17) · Phyllodes Tumor (PHYLL-1) · Principles of HER2 Testing (BINV-A) · Paget’s Disease (PAGET-1) NCCN Guidelines for Patients™ · Breast Cancer During Pregnancy (PREG-1) · Principles of Dedicated Breast MRI Testing available at www.nccn.com · Inflammatory Breast Cancer (IBC-1) (BINV-B) ® The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical ® ® circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network (NCCN ) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN ® Guidelines are copyrighted by National Comprehensive Cancer Network . All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2012. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .
  4. 4. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Updates Breast Cancer Table of Contents Breast Cancer Staging, Discussion Summary of the changes in the 1.2012 version of the Breast Cancer guidelines from the 2.2011 version include: DISCUSSION BINV-1 · The discussion section has been updated to reflect the recent · Modified the workup section: changes in the algorithm. > For clinical stage l and llB, consider additional studies only if directed by signs or symptoms: LCIS-1 7 Added footnote: “Routine systemic staging is not indicated for · Removed footnote: The panel endorses the College of American early breast cancer in the absence of symptoms.” Pathology Protocol for pathology reporting for all invasive and non- 7 Changed pelvic CT to pelvic “diagnostic” CT invasive carcinomas of the breast. 7 Removed “ultrasound” 7 Changed chest CT to chest “diagnostic” CT DCIS-1 > If clinical stage lllA (T3, N1, M0) consider: · Added the following statement to footnote f: “Therefore, the 7 Changed chest CT to chest “diagnostic” CT 7 Bone scan or fluoride PET/CT (category 2B) performance of a sentinel lymph node procedure should be 7 Added footnote: “If FDG PET/ CT are performed and both clearly strongly considered if the patient with apparent pure DCIS is to be indicate bone metastases, bone scan or fluoride PET/CT may not treated with mastectomy or with excision in an anatomic location be needed.” compromising the performance of a future sentinel lymph node 7 Added FDG PET/CT (optional, category 2B) procedure.” 7 Modified footnote h: added “FDG PET/CT can be performed at the DCIS-2 same time as diagnostic CT.” · Modified footnote m: “Some SSRIs like fluoxetine and paroxetine BINV-2 decrease the formation of endoxifen and 4-OH tamoxifen, active · ³ 4 positive axillary nodes and 1-3 positive axillary nodes: metabolites of tamoxifen, and may impact its efficacy. Caution is > Changed “Consider radiation therapy...” to “Strongly consider advised about co-administration of these drugs with tamoxifen. radiation therapy...” changed from (category 3 to 2B). However citalopram and venlafaxine appear to have minimal impact (Also applies to BINV-3) on tamoxifen metabolism. At this time, based on current data the · Modified footnote n: “Consider imaging for systemic staging panel recommends against CYP2D6 testing for women being including, diagnostic CT or MRI, bone scan and optional FDG PET/CT considered for tamoxifen therapy. Co-administration of strong (category 2B) inhibitors of CYP2D6 should be used with caution.” BINV-3 (also applies to BINV-J, footnote 2) · Negative axillary nodes and tumor > 5 cm or margins positive: > Changed “Consider radiation therapy...” to “Strongly consider radiation therapy...” changed from (category 3 to 2B). · Negative axillary nodes and tumor £ 5 cm and close margins: > Added “Consider” to postchemotherapy radiation therapy to chest wall. Continued on the next page Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . UPDATES
  5. 5. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Updates Breast Cancer Table of Contents Breast Cancer Staging, Discussion BINV-5 · Modified footnote oo: “It is unclear that women presenting at time of · Changed “+ trastuzumab” to “with trastuzumab” throughout the initial diagnosis with metastatic disease will benefit from the page. performance of palliative local breast surgery and/or radiation BINV-6 therapy. Generally this palliative local therapy should be considered · Added “± adjuvant chemotherapy (category 2B)” following pN1mi. only after response to initial systemic therapy.” BINV-9 · Added a new footnote: “A single study (S0226) in women with · Changed “colloid” to “mucinous.”(also applies to BINV-4) hormone receptor positive breast cancer and no prior chemotherapy, BINV-10 biological therapy, or endocrine therapy for metastatic disease · Modified the workup section to be consistent with the demonstrated that the addition of fulvestrant to anastrozole resulted changes on BINV-1. in prolongation of time to progression (Hazard rate for recurrence BINV-12 0.80; 95% CI 0.68 - 0.94; stratified log-rank p=0.007) and improvement · Added a header for “Response” with footnote dd. in overall survival (hazard rate 0.81; 95% CI 0.65- 1.00; stratified log- · Added footnote dd: “The accurate assessment of in-breast tumor or rank p = 0.049). Subset analysis suggested that patients without prior regional lymph node response to preoperative chemotherapy is adjuvant tamoxifen and more than 10 years since diagnosis difficult, and should include physical examination and performance experienced the greatest benefit. A study of similar design (FACT) of imaging studies that were abnormal at the time of initial tumor demonstrated no advantage in time to progression with the addition staging.” of fulvestrant to anastrozole (Hazard rate 0.99; 95% CI 0.81-1.20; BINV-14 p=0.91). · Modified the workup section to be consistent with the BINV-19, -20, -21 changes on BINV-1. · Added a link to Principles of Monitoring of Metastatic Disease BINV-15 (BINV-M). · Following response, added “strongly” consider internal mammary BINV-A nodes if not clinically involved and changed (category 3) to · Replaced fluorescence in situ hybridization (FISH) with in situ (category 2B) hybridization (ISH) throughout the page. BINV-16 BINV-C · Removed “Consider” from “Determination of ER/PR/HER2 status in · Modified bullet: “All premenopausal patients should be informed the workup of metastatic disease.” about the potential impact of chemotherapy on fertility and asked BINV-18 about their desire for potential future pregnancies. Patients who may · No prior endocrine therapy within 1 y: desire future pregnancies should be referred to fertility specialists > Removed “or antiestrogen.” before chemotherapy.” > Premenopausal, added “or selective estrogen receptor BINV-D modulators. · This page has been reformatted. > Postmenopausal, added “ or selective estrogen receptor · Added a branch for “FNA or core biopsy positive - axillary dissection modulators or selective estrogen receptor down-regulator level l/ll.” Continued on the next page Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . UPDATES
  6. 6. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Updates Breast Cancer Table of Contents Breast Cancer Staging, Discussion BINV-D BINV-K · The following information was removed from a footnote and placed · Moved AC (doxorubicin/cyclophosphamide) to “Other Adjuvant in the algorithm: Regimens.” > Meets ALL of the following criteria: · Changed “Neoadjuvant” to “Neoadjuvant only.” 7 T1 or T2 tumor BINV-M 7 1 or 2 positive SLNs · Principles of Monitoring Metastatic Disease - this page is new to 7 Breast conserving therapy the guideline. 7 Whole breast RT planned BINV-N 7 No neoadjuvant chemotherapy · A single study (BOLERO-2) in women with hormone receptor · Following “sentinel node negative” inserted “consider” no further positive, her-2 negative metastatic breast cancer and prior therapy surgery (category 1). with a non-steroidal aromatase inhibitor demonstrated BINV-G improvement in time to progression with the addition of · Modified last bullet: Women with a known “or suspected genetic everolimus (an mTOR inhibitor) to exemestane (Hazard rate 0.44; predisposition to breast cancer.” 95% CI 0.36-0.53; log-rank P = <1 x 10-16) and with increase in BINV-J toxicity. No survival analysis is available. A randomized study · Adjuvant endocrine therapy: > Premenopausal: using the mTOR inhibitor temsirolimus in combination with 7 Changed tamoxifen for 2-3 y to “5y” (category 1) followed by endocrine therapy did not demonstrate any improvement in aromatase inhibitor for 5y or no further endocrine therapy. outcome. Consider the addition everolimus to exemestane in > Postmenopausal: women who fulfill the eligibility criteria of BOLERO-2. 7 Added “aromastase inhibitor for 2-3 y (category 1) followed by tamoxifen to complete 5 y (category 1).” PAGET’S-2 7 Tamoxifen for 2-3 y followed by aromatase inhibitor to complete · Modified last node, appropriate systemic adjuvant therapy “per 5y (category 1) changed “or longer” to “or up to 5 y of an DCIS or Invasive Breast Cancer Guidelines.” aromastase inhibitor” (category 2B). · Deleted the following footnote: “This specific patient subset was not PREG-1 included in the trials of aromatase inhibitors given sequentially with · Modified footnote c: There are insufficient safety data to adjuvant tamoxifen. Some women who appear to become recommend general use of taxanes during pregnancy. “Use of postmenopausal on tamoxifen therapy have resumption of ovarian paclitaxel weekly administration after the first trimester acceptable function after discontinuation of tamoxifen and initiation of an if clinically indicated by disease status.” The use of trastuzumab is aromatase inhibitor. Therefore, serial monitoring of plasma estradiol contraindicated during pregnancy. and FSH levels is encouraged in this clinical setting. Should ovarian function resume, the aromatase inhibitor should be discontinued and tamoxifen resumed. See Definition of Menopause (BINV-L).” Continued on the next page Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . UPDATES
  7. 7. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Updates Breast Cancer Table of Contents Breast Cancer Staging, Discussion IBC-1 · Modified the workup section. > Changed chest CT to chest “diagnostic” CT > Bone scan or fluoride PET/CT (category 2B) > Added FDG PET/CT (category 2B) > Modified footnote f: “FDG PET/CT can be performed at the same time as diagnostic CT. The use of PET or PET/CT scanning is not indicated in the staging of clinical stage I, II, or operable III breast cancer. FDG PET/CT is most helpful in situations where standard staging studies are equivocal or suspicious, especially in the setting of locally advanced or metastatic disease. FDG PET/CT may also be helpful in identifying unsuspected regional nodal disease and/or distant metastases in LABC when used in addition to standard staging studies.” · Added footnote: The panel endorses the College of American Pathologists Protocol for pathology reporting for all invasive and non-invasive carcinomas of the breast. · Added footnote: See Principles of HER2 Testing (BINV-A). · Added footnote: See Neoadjuvant/Adjuvant Chemotherapy (BINV-K). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . UPDATES
  8. 8. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Lobular Carcinoma in Situ DIAGNOSIS WORKUP RISK REDUCTION SURVEILLANCE Biopsy was core Perform Ductal carcinoma Manage per needle biopsy surgical in situ (DCIS) or appropriate (less than surgical excision invasive cancer NCCN Guideline biopsy) a,b Lobular · History and carcinoma in physical situ (LCIS) · Diagnostic identified on bilateral breast biopsy mammogram Surveillance as per Stage 0 · Pathology · NCCN Breast Tis, N0, M0 review Cancer Risk Counseling regarding LCIS without risk reduction, see Reduction Initial biopsy was NCCN Breast Cancer Guidelines surgical biopsy a,b other cancer Risk Reduction · NCCN Breast Guidelines) Cancer Screening and Diagnosis Guidelines a LCIS is present on initial biopsy (needle or surgical) or on final excision with or without other proliferative changes (atypical ductal or lobular hyperplasia). b Some variants of LCIS (“pleomorphic LCIS”) may have a similar biological behavior to that of DCIS. Clinicians may consider complete excision with negative margins for pleomorphic LCIS, but outcome data regarding the efficacy of surgical excision to negative margins and/or radiotherapy are lacking. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . LCIS-1
  9. 9. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Ductal Carcinoma in Situ Staging, Discussion DIAGNOSIS WORKUP PRIMARY TREATMENT Lumpectomy d,e without lymph node · History and physical exam surgery f + whole breast radiation · Diagnostic bilateral mammogram therapyg,h,i,j,k (category 1) Ductal carcinoma · Pathology review b or Total mastectomy with or without See in situ (DCIS) · Determination of tumor estrogen Postsurgical Stage 0 receptor (ER) status sentinel node biopsyf,i ± reconstruction l Treatment Tis, N0, M0 a · Genetic counseling if patient is high or (DCIS-2) Lumpectomy d,e without lymph node risk for hereditary breast cancer c surgeryf without radiation therapyg,h,j,k (category 2B) a See NCCN Breast Cancer Screening and Diagnosis Guidelines. b The panel endorses the College of American Pathologists Protocol for pathology reporting for all invasive and non-invasive carcinomas of the breast. http://www.cap.org. c See NCCN Genetic/Familial High-Risk Assessment: Breast and Ovarian Guidelines. d Re-resection(s) may be performed in an effort to obtain negative margins in patients desiring breast conserving therapy. Patients not amenable to margin-free lumpectomy should have total mastectomy. e See Margin Status in DCIS (DCIS-A). f Complete axillary lymph node dissection should not be performed in the absence of evidence of invasive cancer or proven metastatic disease in women with apparent pure DCIS. However, a small proportion of patients with apparent pure DCIS will be found to have invasive cancer at the time of their definitive surgical procedure. Therefore, the performance of a sentinel lymph node procedure should be strongly considered if the patient with apparent pure DCIS is to be treated with mastectomy or with excision in an anatomic location compromising the performance of a future sentinel lymph node procedure. g See Principles of Radiation Therapy (BINV-I). h Complete resection should be documented by analysis of margins and specimen radiography. Post-excision mammography should also be performed whenever uncertainty about adequacy of excision remains. i Patients found to have invasive disease at total mastectomy or re-excision should be managed as stage l or stage ll disease, including lymph node staging. j See Special Considerations to Breast-Conserving Therapy (BINV-G). k Whole-breast radiation therapy following lumpectomy reduces recurrence rates in DCIS by about 50%. Approximately half of the recurrences are invasive and half are DCIS. A number of factors determine that local recurrence risk: palpable mass, larger size, higher grade, close or involved margins, and age under 50 years. If the patient and physician view the individual risk as “low,” some patients may be treated by excision alone. All data evaluating the three local treatments show no differences in patient survival. l See Principles of Breast Reconstruction Following Surgery (BINV-H). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . DCIS-1
  10. 10. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Ductal Carcinoma in Situ DCIS POSTSURGICAL TREATMENT SURVEILLANCE/FOLLOW-UP Risk reduction therapy for ipsilateral breast following breast conserving surgery: Consider tamoxifen m for 5 years for: · Patients treated with breast-conserving therapy · Interval history and physical exam every 6-12 mo for (lumpectomy) and radiation therapy n (category 1), 5 y, then annually especially for those with ER-positive DCIS. The benefit of · Mammogram every 12 mo (and 6-12 mo postradiation tamoxifen for ER-negative DCIS is uncertain therapy if breast conserved [category 2B]) · Patients treated with excision alonen · If treated with tamoxifen, monitor per NCCN Breast Cancer Risk Reduction Guidelines Risk reduction therapy for contralateral breast: · Counseling regarding risk reduction m See also NCCN Breast Cancer Risk Reduction Guidelines m Some SSRIs like fluoxetine and paroxetine decrease the formation of endoxifen and 4-OH tamoxifen, active metabolites of tamoxifen, and may impact efficacy. Caution is advised about co-administration of these drugs with tamoxifen. However, citalopram and venlafaxine appear to have minimal impact on tamoxifen metabolism. At this time, based on current data the panel recommends against CYP2D6 testing for women being considered for tamoxifen therapy. Co-administration of strong inhibitors of CYP2D6 should be used with caution. n Available data suggest tamoxifen provides risk reduction in the ipsilateral breast treated with breast conservation and in the contralateral breast in patients with mastectomy or breast conservation with ER-positive primary tumors. Since a survival advantage has not been demonstrated, individual consideration of risks and benefits is important (See also NCCN Breast Cancer Risk Reduction Guidelines). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . DCIS-2
  11. 11. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Ductal Carcinoma in Situ MARGIN STATUS IN DCIS Substantial controversy exists regarding the definition of a negative pathologic margin in DCIS. Controversy arises out of the heterogeneity of the disease, difficulties in distinguishing the spectrum of hyperplastic conditions, anatomic considerations of the location of the margin, and inadequate prospective data on prognostic factors in DCIS. Margins greater than 10 mm are widely accepted as negative (but may be excessive and may lead to a less optimal cosmetic outcome). Margins less than 1 mm are considered inadequate. With pathologic margins between 1-10 mm, wider margins are generally associated with lower local recurrence rates. However, close surgical margins (<1 mm) at the fibroglandular boundary of the breast (chest wall or skin) do not mandate surgical re-excision but can be an indication for higher boost dose radiation to the involved lumpectomy site (category 2B). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . DCIS-A
  12. 12. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Invasive Breast Cancer CLINICAL WORKUP STAGE · History and physical exam · CBC, platelets · Liver function tests and alkaline phosphatase · Diagnostic bilateral mammogram, ultrasound as necessary Stage I · Pathology review a T1, N0, M0 · Determination of tumor estrogen/progesterone receptor (ER/PR) status and HER2 statusb or · Genetic counseling if patient is high risk for hereditary breast cancer c Stage IIA · Breast M RId (optional) T0, N1, M0 · Consider fertility counseling if indicated e T1, N1, M0 See T2, N0, M0 For clinical stage I-IIB, consider additional studies only if directed by signs or symptoms: f Locoregional or · Bone scan indicated if localized bone pain or elevated alkaline phosphatase Treatment Stage IIB (BINV-2) · Abdominal ± pelvic diagnostic CT or MRI indicated if elevated alkaline phosphatase, abnormal liver T2, N1, M0 function tests, abdominal symptoms, or abnormal physical examination of the abdomen or pelvis T3, N0, M0 · Chest diagnostic CT (if pulmonary symptoms present) or Stage IIIA If clinical stage lllA (T3, N1, M0) consider: T3, N1, M0 · Chest diagnostic CT · Abdominal ± pelvic diagnostic CT or MRI · Bone scan or fluoride PET/CT g (category 2B) · FDG PET/CT h (optional, category 2B) f Routine systemic staging is not indicated for early breast cancer in the absence of symptoms. g If FDG PET/CT are performed and both clearly indicate bone metastases, bone a The panel endorses the College of American Pathologists Protocol for pathology scan or fluoride PET/CT may not be needed. reporting for all invasive and non-invasive carcinomas of the breast. h FDG PET/CT can be performed at the same time as diagnostic CT. The use of PET http://www.cap.org. or PET/CT scanning is not indicated in the staging of clinical stage I, II, or operable b See Principles of HER2 Testing (BINV-A). III breast cancer. FDG PET/CT is most helpful in situations where standard staging c See NCCN Genetics/Familial High-Risk Assessment: Breast and Ovarian studies are equivocal or suspicious, especially in the setting of locally advanced or Guidelines. metastatic disease. FDG PET/CT may also be helpful in identifying unsuspected d See Principles of Dedicated Breast MRI Testing (BINV-B). regional nodal disease and/or distant metastases in LABC when used in addition to e See Fertility and Birth Control After Adjuvant Breast Cancer Treatment (BINV-C). standard staging studies. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . BINV-1
  13. 13. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Invasive Breast Cancer LOCOREGIONAL TREATMENT OF CLINICAL STAGE I, IIA, OR IIB DISEASE OR T3, N1, M0 Radiation therapy to whole breast with or without boost o (by photons, brachytherapy, or electron beam) to tumor bed (category 1), infraclavicular ³ 4 positive n region and supraclavicular area. Strongly consider radiation therapy to axillary nodes internal mammary nodes p (category 2B). Radiation therapy should follow chemotherapy when chemotherapy indicated. Radiation therapy to whole breast with or without boost o (by photons, brachytherapy, or electron beam) to tumor bed (category 1) following chemotherapy when chemotherapy indicated. Strongly consider radiation See Lumpectomy with 1-3 positive therapy to infraclavicular region and supraclavicular area (category 2B). BINV-4 surgical axillary staging axillary nodes Strongly consider radiation therapy to internal mammary nodesp (category 1)i,j,k (category 2B). Radiation therapy should follow chemotherapy when chemotherapy indicated. or Radiation therapy to whole breast with or without boost o (by photons, Negative brachytherapy, or electron beam) to tumor bed or consideration of partial axillary nodes breast irradiation (PBI) in selected patients. o,q Radiation therapy should follow chemotherapy when chemotherapy indicated.r Total mastectomy with surgical axillary See Locoregional Treatment (BINV-3) stagingi,j,l (category 1) ± reconstructionm or If T2 or T3 and fulfills criteria for breast Consider Preoperative Chemotherapy Guideline (BINV-10) conserving therapy except for size k i See m See Principles of Breast Reconstruction Following Surgery (BINV-H). Surgical Axillary Staging (BINV-D). j See Axillary Lymph Node Staging (BINV-E) and n Consider imaging for systemic staging, including diagnostic CT or MRI, bone scan, Margin Status in Infiltrating Carcinoma (BINV-F). and optional FDG PET/CT (category 2B) (See BINV-1). k See Special Considerations to Breast-Conserving Therapy (BINV-G). o See Principles of Radiation Therapy (BINV-I). l Except as outlined in the NCCN Genetics/Familial High-Risk Assessment: Breast p Radiation therapy should be given to the internal mammary lymph nodes if they are and Ovarian Guidelines and the NCCN Breast Cancer Risk Reduction Guidelines, clinically or pathologically positive, otherwise the treatment to the internal mammary prophylactic mastectomy of a breast contralateral to a known unilateral breast nodes is at the discretion of the treating radiation oncologist. CT treatment planning cancer is discouraged. When considered, the small benefits from contralateral should be utilized in all cases where radiation therapy is delivered to the internal prophylactic mastectomy for women with unilateral breast cancer must be mammary lymph nodes. q PBI may be administered prior to chemotherapy. balanced with the risk of recurrent disease from the known ipsilateral breast cancer, psychological and social issues of bilateral mastectomy, and the risks of r Breast irradiation may be omitted in those 70 y of age or older with estrogen- contralateral mastectomy. The use of a prophylactic mastectomy contralateral to a receptor positive, clinically node-negative, T1 tumors who receive adjuvant breast treated with breast-conserving therapy is very strongly discouraged. endocrine therapy (category 1). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . BINV-2
  14. 14. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Invasive Breast Cancer LOCOREGIONAL TREATMENT OF CLINICAL STAGE I, IIA, OR IIB DISEASE OR T3, N1, M0 ³ 4 positive Postchemotherapy radiation therapy to chest wall (category 1) + infraclavicular and supraclavicular axillary nodes n areas.o Strongly consider radiation therapyo,p to internal mammary nodes (category 2B) Strongly consider postchemotherapy radiation therapy to 1-3 positive chest wall + infraclavicular and supraclavicular areas; o if axillary nodes radiation therapy is given, strongly consider internal mammary node radiation therapy o,p (category 2B). Total mastectomy with Negative axillary nodes Consider radiation therapy to chest wall ± infraclavicular See surgical axillary and tumor > 5 cm and supraclavicular nodes. Strongly consider radiation BINV-4 stagingi,j (category 1) or therapy o to internal mammary nodes (category 2B) ± reconstructionm margins positive Negative axillary nodes and tumor £ 5 cm and Consider postchemotherapy radiation therapy o to chest wall close margins (< 1 mm) Negative axillary nodes and tumor £ 5 cm and No radiation therapy margins ³ 1 mm i SeeSurgical Axillary Staging (BINV-D). j See AxillaryLymph Node Staging (BINV-E) and Margin Status in Infiltrating Carcinoma (BINV-F). m See Principles of Breast Reconstruction Following Surgery (BINV-H). n Consider imaging for systemic staging, including diagnostic CT or MRI, bone scan, and optional FDG PET/CT (category 2B) (See BINV-1). o See Principles of Radiation Therapy (BINV-I). p Radiation therapy should be given to the internal mammary lymph nodes that are clinically or pathologically positive, otherwise the treatment to the internal mammary nodes is at the discretion of the treating radiation oncologist. CT treatment planning should be utilized in all cases where radiation therapy is delivered to the internal mammary lymph nodes.. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . BINV-3
  15. 15. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Invasive Breast Cancer HISTOLOGY HORMONE HER2 STATUS SYSTEMIC ADJUVANT TREATMENT RECEPTOR STATUS HER2 positive b See Systemic Adjuvant Treatment - Hormone Receptor Positive - HER2 Positive Disease (BINV-5) ER-positive and/or PR positive See Systemic Adjuvant Treatment - Hormone HER2 negative b Receptor Positive - HER2 Negative Disease (BINV-6) · Ductal s · Lobular · Mixed HER2 positive b See Systemic Adjuvant Treatment - Hormone · Metaplastic Receptor Negative - HER2 Positive Disease (BINV-7) ER-negative and PR-negative HER2 negative b See Systemic Adjuvant Treatment - Hormone Receptor Negative - HER2 Negative Disease (BINV-8) ER-positive and/or PR positive · Tubular See Systemic Adjuvant Treatment - Favorable Histologies (BINV-9) · Mucinous ER-negative and PR-negative b See Principles of HER2 Testing (BINV-A). s This includes medullary and micropapillary subtypes. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . BINV-4
  16. 16. Printed by manuel garcia on 3/13/2012 12:08:36 PM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® NCCN Guidelines Index NCCN Guidelines Version 1.2012 Breast Cancer Table of Contents Staging, Discussion Invasive Breast Cancer SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR POSITIVE - HER2 POSITIVE DISEASE b · Tumor £ 0.5 cm or pN0 Consider adjuvant endocrine therapy · Microinvasive Adjuvant endocrine therapy pN1mi ± adjuvant chemotherapy u,v,w with trastuzumab x pT1, pT2, or pT3; and pN0 or pN1mi Adjuvant endocrine therapy (£ 2 mm axillary Tumor 0.6-1.0 cm ± adjuvant chemotherapy u,v,w Histology: t node metastasis) with trastuzumab x · Ductal · Lobular Adjuvant endocrine therapy · Mixed Tumor > 1 cm + adjuvant chemotherapy · Metaplastic with trastuzumab (category 1) u,v,w Node positive (one or more Adjuvant endocrine therapy metastases > 2 mm to one or more + adjuvant chemotherapy ipsilateral axillary lymph nodes) with trastuzumab (category 1) u,v,w See Follow-Up (BINV-16) See Adjuvant Endocrine Therapy (BINV-J) and Adjuvant Chemotherapy (BINV-K) b See Principles of HER2 Testing (BINV-A). t Mixed lobular and ductal carcinoma as well as metaplastic carcinoma should be graded based on the ductal component and treated based on this grading. The metaplastic or mixed component does not alter prognosis. uEvidence supports that the magnitude of benefit from surgical or radiation ovarian ablation in premenopausal women with hormone-receptor-positive breast cancer is similar to that achieved with CMF alone. Early evidence suggests similar benefits from ovarian suppression (ie, LHRH agonist) as from ovarian ablation. The combination of ovarian ablation/suppression plus endocrine therapy may be superior to suppression alone. The benefit of ovarian ablation/suppression in premenopausal women who have received adjuvant chemotherapy is uncertain. v Chemotherapy and endocrine therapy used as adjuvant therapy should be given sequentially with endocrine therapy following chemotherapy. The benefits of chemotherapy and of endocrine therapy are additive. However, the absolute benefit from chemotherapy may be small. The decision to add chemotherapy to endocrine therapy should be individualized, especially in those with a favorable prognosis where the incremental benefit of chemotherapy may be smaller. Available data suggest that sequential or concurrent endocrine therapy with radiation therapy is acceptable. w There are limited data to make chemotherapy recommendations for those over 70 y old. Treatment should be individualized with consideration of comorbid conditions . x The prognosis of patients with T1a and T1b tumors that are node negative is generally favorable even when HER2 is amplified or over-expressed. This is a population of breast cancer patients that was not studied in the available randomized trials. The decision for use of trastuzumab therapy in this cohort of patients must balance the known toxicities of trastuzumab, such as cardiac toxicity, and the uncertain, absolute benefits that may exist with trastuzumab therapy. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ® ® Version 1.2012, 01/20/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN . BINV-5
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×