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(NCCN Guidelines®) Breast Cancer NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Breast Cancer Version 4.2017 — February 7, 2018 NCCN.org NCCN Guidelines for Patients® available at www.nccn.org/patients Continue Version 4.2017, 02/07/18 National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 6:44:49 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 4.2017 Panel Members NCCN Guidelines Index Table of Contents Breast Cancer Discussion * William J. Gradishar, MD/Chair ‡ † Sharon H. Giordano, MD, MPH † Lori J. Pierce, MD § Robert H. Lurie Comprehensive Cancer The University of Texas University of Michigan Center of Northwestern University MD Anderson Cancer Center Comprehensive Cancer Center * Benjamin O. Anderson, MD/Vice-Chair ¶ Matthew P. Goetz, MD ‡ † Elizabeth C. Reed, MD † ξ Fred Hutchinson Cancer Research Mayo Clinic Cancer Center Fred & Pamela Buffett Cancer Center Center/Seattle Cancer Care Alliance Lori J. Goldstein, MD † Kilian E. Salerno, MD § Ron Balassanian, MD ≠ Fox Chase Cancer Center Roswell Park Cancer Institute UCSF Helen Diller Family Comprehensive Cancer Center Steven J. Isakoff, MD, PhD † Lee S. Schwartzberg, MD ‡ † Massachusetts General Hospital St. Jude Children’s Research Hospital/ Sarah L. Blair, MD ¶ Cancer Center The University of Tennessee UC San Diego Moores Cancer Center Health Science Center Janice Lyons, MD § Harold J. Burstein, MD, PhD † Case Comprehensive Cancer Center/ Amy Sitapati, MD Þ Dana-Farber/Brigham and Women’s University Hospitals Seidman Cancer Center and UC San Diego Moores Cancer Center Cancer Center Cleveland Clinic Taussig Cancer Institute Karen Lisa Smith, MD, MPH † Amy Cyr, MD ¶ P. Kelly Marcom, MD † The Sidney Kimmel Comprehensive Siteman Cancer Center at Barnes- Duke Cancer Institute Cancer Center at Johns Hopkins Jewish Hospital and Washington University School of Medicine Ingrid A. Mayer, MD † Mary Lou Smith, JD, MBA ¥ Vanderbilt-Ingram Cancer Center Research Advocacy Network Anthony D. Elias, MD † University of Colorado Cancer Center Beryl McCormick, MD § Hatem Soliman, MD † Memorial Sloan Kettering Cancer Center Moffitt Cancer Center William B. Farrar, MD ¶ The Ohio State University Comprehensive Meena S. Moran, MD § George Somlo, MD ‡ ξ † Cancer Center - James Cancer Hospital Yale Cancer Center/Smilow Cancer Hospital City of Hope Comprehensive Cancer Center and Solove Research Institute Ruth M. O'Regan, MD † Melinda L. Telli, MD † Andres Forero, MD Þ ‡ † University of Wisconsin Carbone Cancer Center Stanford Cancer Institute University of Alabama at Birmingham Comprehensive Cancer Center Sameer A. Patel, MD Ÿ John H. Ward, MD ‡ † Fox Chase Cancer Center Huntsman Cancer Institute at the University of Utah † Medical oncology § Radiation oncology ‡ Hematology/Oncology ξ Bone marrow transplantation Þ Internal medicine ¥ Patient advocacy NCCN Staff ¶ Surgical oncology * Discussion Section Writing Continue Rashmi Kumar, PhD ≠ Pathology Committee Dorothy A. Shead, MS Ÿ Reconstructive surgery NCCN Guidelines Panel Disclosures Version 4.2017, 02/07/18 National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 6:44:49 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 4.2017 Table of Contents NCCN Guidelines Index Table of Contents Breast Cancer Discussion NCCN Breast Cancer Panel Members Summary of Guidelines Updates Clinical Trials: NCCN believes that Noninvasive Breast Cancer: Lobular Carcinoma In Situ (LCIS-1) the best management for any patient Ductal Carcinoma In Situ (DCIS) Workup and Primary Treatment (DCIS-1) with cancer is in a clinical trial. DCIS Postsurgical Treatment and Surveillance/Follow-up (DCIS-2) Participation in clinical trials is Invasive Breast Cancer: especially encouraged. Clinical Stage, Workup (BINV-1) Locoregional Treatment of Clinical Stage l, llA, or llB Disease or T3,N1, M0 (BINV-2) To find clinical trials online at NCCN Systemic Adjuvant Treatment Member Institutions, click here: Hormone Receptor-Positive HER2-Positive Disease (BINV-5) nccn.org/clinical_trials/physician.html. Hormone Receptor-Positive HER2-Negative Disease (BINV-6) Hormone Receptor-Negative HER2-Positive Disease (BINV-7) NCCN Categories of Evidence and Hormone Receptor-Negative HER2-Negative Disease (BINV-8) Consensus: All recommendations Favorable Histologies (BINV-9) are category 2A unless otherwise Preoperative Systemic Therapy for Operable Breast Cancer (BINV-10) Preoperative Systemic Therapy for Inoperable or Locally Advanced Breast Cancer (Non-Inflammatory)(BINV-14) indicated. Surveillance/Follow-Up (BINV-16) See NCCN Categories of Evidence Recurrent/Stage IV Disease (BINV-17) and Consensus. Treatment of Local and Regional Recurrence (BINV-18) Treatment of Stage IV Disease (BINV-19) Principles of HER2 Testing (BINV-A) Special Considerations: Principles of Dedicated Breast MRI Testing (BINV-B) Phyllodes Tumor (PHYLL-1) Fertility and Birth Control (BINV-C) Paget’s Disease (PAGET-1) Surgical Axillary Staging - Stage l, llA, llB, and IIIA T3, N1, M0 (BINV-D) Breast Cancer During Pregnancy (PREG-1) Axillary Lymph Node Staging (BINV-E) Inflammatory Breast Cancer (IBC-1) Margin Status Recommendations for DCIS and Invasive Breast Cancer (BINV-F) Staging (ST-1) Special Considerations to Breast-Conserving Therapy Requiring Radiation Therapy (BINV-G) Principles of Breast Reconstruction Following Surgery (BINV-H) Principles of Radiation Therapy (BINV-I) Adjuvant Endocrine Therapy (BINV-J) Preoperative/Adjuvant Therapy Regimens (BINV-K) Principles of Preoperative Systemic Therapy (BINV-L) Definition of Menopause (BINV-M) SystemicTherapy for ER and/or PR-Positive Recurrent or Stage IV Disease (BINV-N) Chemotherapy Regimens for Recurrent or Metastatic Breast Cancer (BINV-O) Principles of Monitoring Metastatic Disease (BINV-P) 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. ©2018. Version 4.2017, 02/07/18 National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Anton Kabakov on 3/5/2018 6:44:49 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 4.2017 Updates NCCN Guidelines Index Table of Contents Breast Cancer Discussion Updates in Version 4.2017 of the NCCN Guidelines for Breast Cancer from Version 3.2017 include: DCIS-1 apparent pure DCIS is to be treated with mastectomy or with excision in • Modified "Lumpectomy without lymph node surgery + whole breast an anatomic location compromising the performance of a future sentinel radiation therapy (category 1) with or without boost to tumor bed." lymph node procedure. Complete axillary lymph node dissection should by moving "(category 1)" from the end of recommendation to after not be performed in the absence of evidence of invasive cancer or "whole breast radiation therapy." proven axillary metastatic disease in women with apparent pure DCIS or • Modified footnote "e": "Re-resection(s) may be performed in an effort mammographically detected DCIS with microcalcifications. to obtain negative margins in patients desiring breast-conserving BINV-13 therapy. Patients in whom adequate surgical margins cannot be • Corrected recommendation for adjuvant therapy, post lumpectomy achieved with lumpectomy should undergo a total mastectomy. "Strongly consider radiation to the whole breast + infraclavicular region, For definition of adequate surgical margins, see Margin Status supraclavicular area, internal mammary nodes, and any part of the Recommendations for DCIS and Invasive Breast Cancer (BINV-F)." axillary bed at risk for clinical N1, ypN0." • Modified footnote "f": In" certain situations, SLNB may be BINV-F considered. Complete axillary lymph node dissection should not be • Modified the second bullet: For" mammographically-detected DCIS performed in the absence of evidence of invasive cancer or proven with microcalcifications, complete resection should be documented axillary metastatic disease in women with apparent pure DCIS. by analysis of margins and specimen radiography. Post-excision However, a small proportion of patients with apparent pure DCIS mammography could also be performed
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