NCCN VERSION 2 2015

The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

MS-43

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

felt to be standard. Tamoxifen (or an aromatase inhibitor if

postmenopausal) should be added for those with hormone

receptor-positive tumors, and trastuzumab should be given to those with

HER2-positive tumors. Post-treatment follow-up for women with stage

III disease is the same as for women with early-stage invasive breast

cancer.

Post-Therapy Surveillance and Follow-up

Post-therapy follow-up is optimally performed by members of the

treatment team and includes the performance of regular history/physical

examinations every 4 to 6 months for the first 5 years after primary

therapy and annually thereafter. Mammography should be performed

annually.

The routine performance of alkaline phosphatase and liver function

tests are not included in the guidelines.

372-374

In addition, the Panel notes

no evidence to support the use of “tumor markers” for breast cancer,

and routine bone scans, CT scans, MRI scans, PET scans, or

ultrasound examinations in the asymptomatic patient provide no

advantage in survival or ability to palliate recurrent disease and are,

therefore, not recommended.

95,375

The use of dedicated breast MRI may be considered as an option for

post-therapy surveillance and follow-up in women at high risk for

bilateral disease, such as carriers of

BRCA1/2

mutations. Rates of

contralateral breast cancer following either breast-conserving therapy or

mastectomy have been reported to be increased in women with

BRCA1/2

mutations when compared with patients with sporadic breast

cancer.

376-378

(see

NCCN Guidelines for Genetic/Familial High-Risk

Assessment: Breast and Ovarian

;

NCCN Guidelines for Breast Cancer

Screening and Diagnosis

The panel recommends that women with intact uteri who are taking

adjuvant tamoxifen should have yearly gynecologic assessments and

rapid evaluation of any vaginal spotting that might occur because of the

risk of tamoxifen-associated endometrial carcinoma in postmenopausal

women.

379

The performance of routine endometrial biopsy or

ultrasonography in the asymptomatic woman is not recommended.

Neither test has demonstrated utility as a screening test in any

population of women. The vast majority of women with

tamoxifen-associated uterine carcinoma have early vaginal spotting.

If an adjuvant aromatase inhibitor is considered in women with

amenorrhea following treatment, baseline levels of estradiol and

gonadotropin followed by serial monitoring of these hormones should be

performed if endocrine therapy with an aromatase inhibitor is initiated.

309

Bilateral oophorectomy assures postmenopausal status in young

women with therapy-induced amenorrhea and may be considered prior

to initiating therapy with an aromatase inhibitor in a young woman.

Symptom management for women on adjuvant endocrine therapies

often requires treatment of hot flashes and the treatment of concurrent

depression. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor

(SNRI) has been studied and is an effective intervention in decreasing

hot flashes.

380-383

There is evidence suggesting that concomitant use of

tamoxifen with certain SSRIs (eg, paroxetine, fluoxetine) may decrease

plasma levels of endoxifen, an active metabolite of tamoxifen.

384,385

These SSRIs/SNRIs may interfere with the enzymatic conversion of

tamoxifen to endoxifen by inhibiting a particular isoform of

CYP2D6

However, the mild CYP2D6 inhibitors such as citalopram, escitalopram,

sertraline, and venlafaxine appear to have no or only minimal effect on

tamoxifen metabolism.

309,386,387