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-57

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Symposium were similar showing that surgical treatment of primary

tumors in woman presenting with stage IV disease does not produce an

increase in OS.

510,511

Nevertheless, the panel recognizes the need for randomized clinical

trials that will address the risks and benefits of local therapy for patients

with stage IV disease while eliminating selection biases. Patient

enrollment in such trials is encouraged.

Distant Sites of Recurrence Requiring Consideration of Therapies Local

to the Metastatic Site

Surgery, radiation, or regional chemotherapy (eg, intrathecal

methotrexate) may be indicated as needed for localized clinical

scenarios such as brain metastases, leptomeningeal disease, choroid

metastases, pleural effusion, pericardial effusion, biliary obstruction,

ureteral obstruction, impending pathologic fracture, cord compression,

localized painful bone, or soft-tissue disease.

The guidelines include consideration of the addition of hyperthermia to

irradiation for localized recurrences/metastasis (category 3). There have

been several prospective randomized trials comparing radiation to

radiation plus hyperthermia in the treatment of locally

advanced/recurrent cancers, primarily breast cancer chest wall

recurrences.

512,513

While there is heterogeneity among the study results,

a series with strict quality assurance demonstrated a statistically

significant increase in local tumor response and greater duration of local

control with the addition of hyperthermia to radiation compared to

radiation alone.

512

No differences in OS have been demonstrated.

Delivery of local hyperthermia is technically demanding and requires

specialized expertise and equipment (eg, the monitoring of

temperatures and management of possible tissue burns). The panel

thus recommends that the use of hyperthermia be limited to treatment

centers with appropriate training, expertise, and equipment. The

addition of hyperthermia generated substantial discussion and

controversy among the panel and is a category 3 recommendation.

Monitoring Metastatic Disease

Monitoring the treatment of metastatic breast cancer involves a wide

array of assessments and the need for the clinician to integrate several

different forms of information, to make a determination of the

effectiveness of treatment and the acceptability of toxicity. The

information includes those from direct observations of the patient

including patient reported symptoms, performance status, change in

weight, and physical examination; laboratory tests such as alkaline

phosphatase, liver function, blood counts, and calcium; radiographic

imaging; functional imaging; and, where appropriate, tumor biomarkers.

The results of these evaluations generally are classified as response,

continued response to treatment, stable disease, uncertainty regarding

disease status, or progression of disease. The clinician typically must

assess and balance multiple different forms of information to make a

determination regarding whether disease is being controlled and the

toxicity of treatment is acceptable. Sometimes this information may be

contradictory.

The panel recommends using widely accepted criteria for reporting

response, stability, and progression of disease such as the RECIST

criteria

514

and the WHO criteria.

515

The NCCN Panel also recommends

using the same method of assessment over time. For example, an

abnormality initially found on diagnostic CT scan of the chest should be

monitored with repeat diagnostic CT scans of the chest.

The optimal frequency of testing is uncertain, and is primarily based on

the monitoring strategies utilized in breast cancer clinical trials. The

page titled

Principles of Monitoring Metastatic Disease

in the algorithms