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-66

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Testing for immunohistochemical markers including ER/PR and HER2

is recommended. Elevated ER/PR levels provide strong evidence for a

breast cancer diagnosis.

601

MRI of the breast should be considered for a

patient with histopathologic evidence of breast cancer when

mammography and ultrasound are not adequate to assess the extent of

the disease. MRI may be especially helpful in women with dense breast

tissue, positive axillary nodes, and suspected occult primary breast

tumor or to evaluate the chest wall

602

Breast MRI has been shown to be

useful in identifying the primary site in patients with occult primary

breast cancer and may also facilitate breast conservation in selected

women by allowing for lumpectomy instead of mastectomy.

598,603

In one

report, the primary site was identified using MRI in about half of the

women presenting with axillary metastases, irrespective of the breast

density.

604

The

NCCN Guidelines for Occult Primary Cancer

also provide

recommendations for additional workup, including chest and abdominal

CT to evaluate for evidence of distant metastases for patients

diagnosed with adenocarcinoma (or carcinoma not otherwise specified)

of the axillary nodes without evidence of a primary breast lesion. In

particular, breast MRI and ultrasound are recommended. Axillary

ultrasound should also be performed.

Treatment for Possible Primary Breast Cancer

Patients with MRI-positive breast disease should undergo evaluation

with ultrasound or MRI-guided biopsy and receive treatment according

to the clinical stage of the breast cancer. Treatment recommendations

for those with MRI-negative disease are based on nodal status. For

patients with T0, N1, M0 disease, options include mastectomy plus

axillary nodal dissection or axillary nodal dissection plus whole breast

irradiation with or without nodal irradiation. Systemic chemotherapy,

endocrine therapy, or trastuzumab is given according to the

recommendations for stage II or III disease. Neoadjuvant

chemotherapy, trastuzumab, and endocrine therapy should be

considered for patients with T0, N2-N3, M0 disease followed by axillary

nodal dissection and mastectomy as for patients with locally advanced

disease.

Summary

The therapeutic options for patients with noninvasive or invasive breast

cancer are complex and varied. In many situations, the patient and

physician have the responsibility to jointly explore and select the most

appropriate option from among the available alternatives.

With few exceptions, the evaluation, treatment, and follow-up

recommendations in these guidelines are based on the results of past

and present clinical trials. However, there is not a single clinical

situation in which the treatment of breast cancer has been optimized

with respect to either maximizing cure or minimizing toxicity and

disfigurement. Therefore, patient/physician participation in prospective

clinical trials allows patients to not only receive state-of-the-art cancer

treatment but also to contribute to improving the treatment outcomes.