NCCN VERSION 2 2015

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

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NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Overall, approximately half of the local recurrences after initial treatment

for a pure DCIS are again DCIS, and the others are invasive cancer.

Those with local recurrences that are invasive should receive systemic

treatment as appropriate for a newly diagnosed invasive breast cancer.

Invasive Breast Cancer

Stage I, IIA, IIB, or T3N1M0 Invasive Breast Cancer

Staging and Workup

The recommended workup and staging of invasive breast cancer

includes: history and physical exam; a CBC count; liver function tests

;

bilateral diagnostic mammography; breast ultrasonography, if

necessary; tumor ER and PR determinations; HER2 tumor status

determination; and pathology review. Genetic counseling is

recommended if the patient is considered to be at high risk for

hereditary breast cancer as defined by the

NCCN Guidelines for

Genetic/Familial High-Risk Assessment: Breast and Ovarian

Use of MRI to evaluate women considering breast-conserving therapy is

optional. If MRI imaging of the breast is performed, it should be done

with a dedicated breast coil, with consultation with the multidisciplinary

treatment team, and by a breast imaging team capable of performing

MRI-guided biopsy. The limitations of breast MRI include a high

percentage of false-positive findings.

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MRI imaging of the breast,

therefore, should generally be considered in the staging of breast

cancer for patients whose breasts cannot be imaged adequately with

mammography and ultrasound (eg, women with very dense breast

tissue; women with positive axillary nodal status and occult primary

tumor presumed to originate in the breast; to evaluate the chest wall).

No randomized, prospective assessment of the utility of MRI in staging

or treatment decision making in breast cancer treatment is available.

One retrospective study suggested an outcome benefit

whereas

another did not.

One systematic review

documented breast MRI

staging to alter surgical treatment in 7.8% to 33.3% of women.

However, no differences in outcome, if any, can be demonstrated in that

analysis. Patients should not be denied the option of breast

conservation therapy based upon MRI findings alone without tissue

sampling.

Fertility

Numerous epidemiologic studies have demonstrated that child-bearing

after treatment for invasive breast cancer does not increase rates of

recurrence or death from breast cancer.

The offspring of pregnancies

after treatment for breast cancer do not have an increased rate of birth

defects or other serious childhood illness. However, treatment for

breast cancer, especially with cytotoxic agents, may impair fertility.

Therefore, it is reasonable and appropriate to consider fertility

preservation prior to breast cancer treatment in young women who

desire to bear children following breast cancer therapy.

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No high-level

evidence demonstrates that ovarian suppression or other interventions

decrease the toxicity of cytotoxic chemotherapy on the premenopausal

ovary.

However, many women, especially those younger than age 35,

regain menstrual function within 2 years of completing chemotherapy.

Resumption of menses does not necessarily correlate with fertility, and

fertility may be preserved without menses.

All premenopausal patients should be informed about the potential

impact of chemotherapy on fertility and asked about their desire for

potential future pregnancies. Should a newly diagnosed premenopausal

woman with breast cancer desire to bear children after breast cancer

treatment, she should receive consultation with a physician with

expertise in fertility prior to the initiation of chemotherapy.

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Multiple

factors to consider in making a decision for fertility preservation include