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-46

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

breast-conserving therapy with mastectomy in patients with stage I and

stage II disease. The 133 (approximately 8%) patients experiencing a

local recurrence as an initial event were approximately equally divided

between those who had undergone mastectomy and those who had

received breast-conserving therapy as initial treatment for breast

cancer. Of those in the former group, 51 (76%) were able to undergo

radiation therapy with or without surgery as treatment for local disease

recurrence. No difference in survival emerged when patients receiving

salvage treatment after initial treatment with mastectomy or

breast-conserving therapy were compared; approximately 50% of both

groups were alive at 10-year follow-up.

407

Mastectomy-treated patients should undergo surgical resection of the

local recurrence (if it can be accomplished without heroic surgery) and

involved-field radiation therapy to the chest wall and supraclavicular

area (if the chest wall was not previously treated or if additional

radiation therapy may be safely administered). The use of surgical

resection in this setting implies the use of limited excision of disease

with the goal of obtaining clear margins of resection. Unresectable chest

wall recurrent disease should be treated with radiation therapy if no

prior radiation has been given. Women with a local recurrence of

disease after initial breast-conserving therapy should undergo a total

mastectomy and axillary staging if a level I/II axillary dissection was not

previously performed. Limited data suggest that a repeat SLN biopsy

following local recurrence of disease may be successfully performed in

80% of women who have previously undergone breast-conserving

therapy and sentinel node biopsy.

408

The consensus of the panel is that

the preferred surgical approach for most women with a local recurrence

following breast-conserving therapy and sentinel node biopsy is

mastectomy and a level I/II axillary dissection, although sentinel node

biopsy in lieu of a level I/II axillary dissection can be considered if prior

axillary staging was done by sentinel node biopsy only.

After local treatment, women with local recurrences only should be

considered for limited duration systemic chemotherapy or endocrine

therapy similar to that outlined in the adjuvant chemotherapy section.

The panel emphasized the importance of individualizing treatment

strategies in patients with a recurrence of disease limited to a local site.

Management of Stage IV or Recurrent Metastatic Disease

The systemic treatment of breast cancer recurrence or stage IV disease

prolongs survival and enhances quality of life but is not curative.

Therefore, treatments associated with minimal toxicity are preferred.

Thus, the use of the minimally toxic endocrine therapies is preferred to

the use of cytotoxic therapy whenever reasonable.

409

Guideline Stratification for Therapy in Systemic Disease

Patients with recurrence of breast cancer or metastatic breast cancer at

diagnosis are initially stratified according to whether bone metastasis is

present. These two patient subsets are then stratified further by tumor

hormone receptor and HER2 status.

Supportive Therapy for Bone Metastases

Treatment targeting osteoclast activity is of value in patients with

metastatic breast cancer in bone to prevent bone fractures, bone pain

requiring radiation therapy, spinal cord compression, and hypercalcemia

(skeletal related events; SREs).

410-412

The bisphosphonates zoledronic

acid or pamidronate have been used for this purpose, and there is

extensive clinical trial support for their efficacy in prevention of SREs

(see section below on bisphosphonates). A single, randomized, active,

controlled trial in metastatic breast cancer showed equivalency and

superiority of time to the occurrence of SRE with denosumab, a fully