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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Breast Cancer Screening and Diagnosis Version 1.2019 — May 17, 2019 NCCN.org Continue Version 1.2019, 05/17/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Breast Cancer Screening and Diagnosis Discussion *Therese B. Bevers, MD/Chair Þ Richard Gray, MD ¶ Liane Philpotts, MD ф The University of Texas Mayo Clinic Cancer Center Yale Cancer Center/Smilow Cancer Hospital MD Anderson Cancer Center Randall E. Harris, MD, PhD Þ ≠ Donna Plecha, MD ф *Mark Helvie, MD/Vice-Chair ф Þ The Ohio State University Comprehensive Case Comprehensive Cancer Center/ University of Michigan Cancer Center - James Cancer Hospital University Hospitals Seidman Cancer Rogel Cancer Center and Solove Research Institute Center and Cleveland Clinic Taussig Cancer Institute Ermelinda Bonaccio, MD ф Teresa Helsten, MD † Roswell Park Comprehensive Cancer Center UC San Diego Moores Cancer Center Jennifer K. Plichta, MD, MS ¶ Duke Cancer Institute Kristine E. Calhoun, MD ¶ Linda Hodgkiss, MD ф University of Washington/ St. Jude Children’s Research Hospital/ Mary Lou Smith, JD, MBA ¥ Seattle Cancer Care Alliance The University of Tennessee Health Research Advocacy Network Science Center Melissa Camp, MD ¶ Roberta M. Strigel, MD, MS ф The Sidney Kimmel Comprehensive Tamarya L. Hoyt, MD ф University of Wisconsin Cancer Center at Johns Hopkins Vanderbilt-Ingram Cancer Center Carbone Cancer Center Mary B. Daly, MD, PhD † John G. Huff, MD ф Lusine Tumyan, MD ф Fox Chase Cancer Center Vanderbilt-Ingram Cancer Center City of Hope National Medical Center Constance Dobbins Lehman, MD, PhD ф Maxine S. Jochelson, MD ф Cheryl Williams, MD ф Massachusetts General Hospital Memorial Sloan Kettering Cancer Center Fred & Pamela Buffett Cancer Center Cancer Center Bethany L. Niell, MD, PhD ф Nicole S. Winkler, MD ф William B. Farrar, MD ¶ Moffitt Cancer Center Huntsman Cancer Institute The Ohio State University Comprehensive at the University of Utah Cancer Center - James Cancer Hospital Catherine C. Parker, MD ¶ and Solove Research Institute O'Neal Comprehensive Catherine Young, MD ф Cancer Center at UAB Siteman Cancer Center at Barnes- Judy E. Garber, MD, MPH † Jewish Hospital and Washington Dana-Farber/Brigham and Mark Pearlman, MD Ω ¶ University School of Medicine Women’s Cancer Center University of Michigan Rogel Cancer Center ф Diagnostic/Interventional † Medical oncology radiology ≠Pathology Ω Gynecologic oncology/ ¥ Patient advocacy NCCN Guidelines Panel Disclosures Gynecology ¶ Surgery/Surgical oncology NCCN Continue Þ Internist/Internal medicine, * Discussion Section Writing Mary Anne Bergman including family practice, Committee preventive management Rashmi Kumar, PhD Version 1.2019, 05/17/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Breast Cancer Screening and Diagnosis Discussion NCCN Breast Cancer Screening and Diagnosis Panel Members Clinical Trials: NCCN believes that Summary of the Guidelines Updates the best management for any patient with cancer is in a clinical trial. Participation in clinical trials is Clinical Encounter Including Risk Assessment (BSCR-1) especially encouraged. Average Risk, Screening/Follow-Up (BSCR-1) To find clinical trials online at NCCN Increased Risk, Screening/Follow-Up (BSCR-2) Member Institutions, click here: Symptomatic During Clinical Encounter, Presenting Signs/Symptoms (BSCR-4) nccn.org/clinical_trials/clinicians.aspx. • Palpable Mass, Age ≥30 Years (BSCR-5) NCCN Categories of Evidence and Consensus: All recommendations • Palpable Mass, Age <30 Years (BSCR-11) are category 2A unless otherwise • Nipple Discharge, No Palpable Mass (BSCR-13) indicated. • Asymmetric Thickening/Nodularity (BSCR-14) See NCCN Categories of Evidence • Skin Changes (BSCR-15) and Consensus. Persistent or Severe Breast Pain (BSCR-16) Recommendations for Follow-up of Axillary Mass (BSCR-18) Breast Cancer Presentation in Men (BSCR-19) Mammographic Evaluation (BSCR-20) Breast Screening Considerations (BSCR-A) Risk Factors Used in the Modified Gail Model, Age ≥35 Years (BSCR-B) Assessment Category Definitions (BSCR-C) 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. ©2019. Version 1.2019, 05/17/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Breast Cancer Screening and Diagnosis Discussion Updates in Version 1.2019 of the NCCN Guidelines for Breast Cancer Screening and Diagnosis from Version 3.2018 include: BSCR-1 Footnotes: Increased Risk: • "m" modified: High-quality breast MRIlimitations include having: a need • 2nd bullet modified: Women who have a lifetime risk ≥20% as defined by for requires a dedicated breast coil, the ability to perform access to biopsy models that are largely dependent on family history under MRI guidance, experienced radiologists in breast MRI, and regional • 5th bullet modified: Women with a history of LCIS or ADH/ALH and greater availability. Breast MRI is performed preferably days 7–15 of menstrual than 20% lifetime risk cycle for premenopausal women. MRI should be integrated correlated with other breast imaging modalities. • 6th bullet, 1st sub-bullet modified: Referral to genetic counseloror similarly • "n" is new to the page, Consider whole breast ultrasound for those who trained provider, if not already done qualify but cannot undergo MRI, corresponding to annual breast MRI. (Also Footnotes: for BSCR-3) • " b" modified: Medicare and insurers allow the patient direct access to BSCR-3 . scheduling for screening mammography Increased Risk: • "c" modified: At minimum medical and family history should be obtained • Lower pathway modified: Women with ahistory of LCIS or ADH/ALH and and clinical encounter should encompass ongoing risk assessment, risk greater than 20% lifetime risk reduction counseling, as well as a clinical breast exam by a licensed • 3rd bullet modified: Consider annual breast MRI provider. Refer to the NCCN Guidelines for Breast Cancer Risk Reduction BSCR-4 for a detailed qualitative and quantitative assessment. (Also for BSCR-2, • New pathway off, Symptomatic during clinical encounter: BSCR-3) Breast implant-related symptoms (effusion, enlargement, mass ulceration) • "i" modified: Randomized trials comparing clinical breast exam versus no >1 year post-implantation screening have not been performed. Rationale for recommending clinical Consultation with multidisciplinary team with experience with implant encounter is to maximize earliest detection of breast cancers and assure related problems including BIA-ALCL ongoing risk assessment. (Also for BSCR-2, BSCR-3) For diagnostic workup of BIA-ALCL, see NCCN Guidelines for T-Cell • "l" modified: Tomosynthesis can decrease call back rates and appears Lymphomas to improve cancer detection but has not been sufficiently studied to Footnotes: determine if it improves disease-specific mortality. (Also for BSCR-2, • "o" is new to the page: Individuals with breast implants have a risk of BSCR-3) developing breast implant-associated anaplastic large cell lymphoma (BIA- BSCR-2 ALCL) (Average 8–10 years after implantation). Majority of cases have been Screening/Follow-up: seen in textured implants. • 1st sub-bullet under Clinical encounter modified: to begin when identified BSCR-5 as being at increased risk but not prior to age 21 y Diagnostic Evaluation: • 2nd sub-bullet modified: Referral to genetic counselingor similarly trained • +Ultrasound was added to Diagnostic mammogram provider, if not already done • 3rd column, significantly modified. • 1st sub-bullet under Annual screening modified: to begin 10 years prior to Work-up: the youngest family member with breast cancer but not prior to age 30 y • Revised: Follow-up After Core Needle Biopsy (See BSCR-8) Continued Version 1.2019, 05/17/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN. UPDATES NCCN Guidelines Index NCCN Guidelines Version 1.2019 Table of Contents Breast Cancer Screening and Diagnosis Discussion Updates in Version 1.2019 of the NCCN Guidelines for Breast Cancer Screening and Diagnosis from Version
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