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-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.

These recommendations are supported by a study evaluating patients

with newly diagnosed breast cancer by bone scan, liver

ultrasonography, and chest radiography.

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.

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