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-44

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Follow-up also includes assessment of patient adherence to ongoing

medication regimens such as endocrine therapies. Predictors of poor

adherence to medication include the presence of side effects

associated with the medication, and incomplete understanding by the

patient of the benefits associated with regular administration of the

medication.

388

The panel recommends the implementation of simple

strategies to enhance patient adherence to endocrine therapy, such as

direct questioning of the patient during office visits, as well as brief,

clear explanations on the value of taking the medication regularly and

the therapeutic importance of longer durations of endocrine therapy.

Evidence suggests that a healthy lifestyle may lead to better breast

cancer outcomes. A nested case control study of 369 women with

ER-positive tumors who developed a second primary breast cancer

compared with 734 matched control patients who did not develop a

second primary tumor showed an association between obesity (BMI

≥30), smoking, and alcohol consumption and contralateral breast

cancer.

389

A prospective study of 1490 women diagnosed with stage I–

III breast cancer showed an association between high fruit and

vegetable consumption, physical activity, and improved survivorship,

regardless of obesity.

390

Thus, the NCCN Panel recommends an active

lifestyle and ideal body weight (BMI 20–25) for optimal overall health

and breast cancer outcomes.

Many young women treated for breast cancer remain or regain

premenopausal status following treatment for breast cancer. For these

women, the NCCN Panel discourages the use of hormonal birth control

methods, regardless of the hormone receptor status of the tumor.

391

Alternative birth control methods are recommended, including

intrauterine devices, barrier methods, and, for those with no intent of

future pregnancy, tubal ligation or vasectomy for the partner.

Breastfeeding during endocrine or chemotherapy treatment is not

recommended by the NCCN Panel because of risks to the infant.

Breastfeeding after breast-conserving treatment for breast cancer is not

contraindicated. However, lactation from an irradiated breast may not

be possible, or may occur only with a diminished capacity.

391,392

The panel recommends that women on an adjuvant aromatase inhibitor

or who experience ovarian failure secondary to treatment should have

monitoring of bone health with a bone mineral density determination at

baseline and periodically thereafter. The use of estrogen, progesterone,

or selective ER modulators to treat osteoporosis or osteopenia in

women with breast cancer is discouraged. The use of a bisphosphonate

is generally the preferred intervention to improve bone mineral density.

Optimal duration of bisphosphonate therapy has not been established.

Factors to consider for duration of anti-osteoporosis therapy include

bone mineral density, response to therapy, and risk factors for

continued bone loss or fracture. Women treated with a bisphosphonate

should undergo a dental examination with preventive dentistry prior to

the initiation of therapy, and should take supplemental calcium and

vitamin D.

Stage IV Metastatic or Recurrent Breast Cancer

Staging and Workup

The staging evaluation of women who present with metastatic or

recurrent breast cancer includes history and physical exam; the

performance of a CBC, liver function tests, chest diagnostic CT, bone

scan, and radiographs of any long or weight-bearing bones that are

painful or appear abnormal on bone scan; consideration of diagnostic

CT of the abdomen (with or without diagnostic CT of the pelvis) or MRI

scan of the abdomen; and biopsy documentation of first recurrence if

possible. The panel generally discourages the use of sodium fluoride

PET or PET/CT scans for the evaluation of patients with recurrent