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Version 2.2015, 03/11/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved.
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MS-12
NCCN Guidelines Index
Breast Cancer Table of Contents
Discussion
NCCN Guidelines Version 2.2015
Breast Cancer
patient preference, the age of the woman, risk of premature ovarian
failure based upon anticipated chemotherapy, and length of optimal
endocrine therapy. It is important for fetal safety that women do not
become pregnant during breast cancer treatment. Also see
NCCN
Guidelines for Adolescent and Young Adult Oncology
.
Additional Workup for Stage I-IIB Disease
For patients with stage I-IIB disease, additional tests may be considered
based on the signs and symptoms. A bone scan is indicated for patients
presenting with localized bone pain or elevated alkaline phosphatase. If
pulmonary symptoms are present, chest diagnostic CT is indicated.
Abdominal imaging using diagnostic CT or MRI is indicated if the patient
has elevated alkaline phosphatase, abnormal results on liver function
tests, abdominal symptoms, or abnormal physical examination of the
abdomen or pelvis. These studies are not indicated in patients with
stage I disease
without
signs/symptoms of metastatic disease, nor are
they needed in many other patients with early-stage breast cancer.
90
These recommendations are supported by a study evaluating patients
with newly diagnosed breast cancer by bone scan, liver
ultrasonography, and chest radiography.
91
Metastases were identified
by bone scan in 5.1%, 5.6%, and 14% of patients with stage I, II, and III
disease, respectively, and no evidence of metastasis was detected by
liver ultrasonography or chest radiography in patients with stage I or II
disease.
91
The NCCN Panel recommends
against
the use of PET or PET/CT
scanning in the staging of these early-stage patients. The
recommendation against the use of PET scanning is supported by the
high false-negative rate in the detection of lesions that are small (<1
cm) and/or low grade, the low sensitivity for detection of axillary nodal
metastases, the low prior probability of these patients having detectable
metastatic disease, and the high rate of false-positive scans.
92-97
Additional Workup for Stage IIIA (T3, NI, MO) Disease
For patients with clinical stage IIIA (T3, N1, M0) disease, additional
staging studies including bone scan or sodium fluoride PET scan
(category 2B), abdominal imaging using diagnostic CT or MRI, and
chest imaging using diagnostic CT should be considered. Ultrasound is
an alternative when diagnostic CT or MRI is unavailable.
Fluorodeoxyglucose (FDG) PET scan is optional (category 2B). FDG
PET scan can be considered at the same time as diagnostic CT. If FDG
PET and diagnostic CT are performed and both clearly indicate bone
metastases, bone scan or sodium fluoride PET/CT may not be needed.
PET/CT scanning is discussed in detail under the section titled
Stage III
Invasive Breast Cancer
.
Locoregional Treatment
Several randomized trials document that mastectomy with ALN
dissection is equivalent to breast-conserving therapy with lumpectomy,
axillary dissection, and whole breast irradiation, as primary breast
treatment for the majority of women with stage I and stage II breast
cancers (category 1).
98-101
The panel recommends whole breast irradiation to include the majority
of the breast tissue; breast irradiation should be performed following
CT-based treatment planning to limit irradiation exposure of the heart
and lungs, and to assure adequate coverage of the primary tumor and
surgical site. Tissue wedging, forward planning with segments (step and
shoot), or intensity-modulated radiation therapy (IMRT) is
recommended.
102
Dose/fraction schedules of either 50 Gy in 25
fractions over 35 days or 42.5 Gy in 16 fractions over 22 days have
been prospectively evaluated and are comparable with respect to DFS
and OS in a study of women with node-negative, early-stage breast
cancer with a median follow-up of 69 months.
103,104