NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

Follow-up also includes assessment of patient adherence to ongoing medication regimens such as endocrine therapies. Predictors of poor adherence to medication include the presence of side effects associated with the medication, and incomplete understanding by the patient of the benefits associated with regular administration of the medication. 388 The panel recommends the implementation of simple strategies to enhance patient adherence to endocrine therapy, such as direct questioning of the patient during office visits, as well as brief, clear explanations on the value of taking the medication regularly and the therapeutic importance of longer durations of endocrine therapy. Evidence suggests that a healthy lifestyle may lead to better breast cancer outcomes. A nested case control study of 369 women with ER-positive tumors who developed a second primary breast cancer compared with 734 matched control patients who did not develop a second primary tumor showed an association between obesity (BMI ≥30), smoking, and alcohol consumption and contralateral breast cancer. 389 A prospective study of 1490 women diagnosed with stage I– III breast cancer showed an association between high fruit and vegetable consumption, physical activity, and improved survivorship, regardless of obesity. 390 Thus, the NCCN Panel recommends an active lifestyle and ideal body weight (BMI 20–25) for optimal overall health and breast cancer outcomes. Many young women treated for breast cancer remain or regain premenopausal status following treatment for breast cancer. For these women, the NCCN Panel discourages the use of hormonal birth control methods, regardless of the hormone receptor status of the tumor. 391 Alternative birth control methods are recommended, including intrauterine devices, barrier methods, and, for those with no intent of future pregnancy, tubal ligation or vasectomy for the partner. Breastfeeding during endocrine or chemotherapy treatment is not

recommended by the NCCN Panel because of risks to the infant. Breastfeeding after breast-conserving treatment for breast cancer is not contraindicated. However, lactation from an irradiated breast may not be possible, or may occur only with a diminished capacity. 391,392 The panel recommends that women on an adjuvant aromatase inhibitor or who experience ovarian failure secondary to treatment should have monitoring of bone health with a bone mineral density determination at baseline and periodically thereafter. The use of estrogen, progesterone, or selective ER modulators to treat osteoporosis or osteopenia in women with breast cancer is discouraged. The use of a bisphosphonate is generally the preferred intervention to improve bone mineral density. Optimal duration of bisphosphonate therapy has not been established. Factors to consider for duration of anti-osteoporosis therapy include bone mineral density, response to therapy, and risk factors for continued bone loss or fracture. Women treated with a bisphosphonate should undergo a dental examination with preventive dentistry prior to the initiation of therapy, and should take supplemental calcium and vitamin D. Stage IV Metastatic or Recurrent Breast Cancer Staging and Workup The staging evaluation of women who present with metastatic or recurrent breast cancer includes history and physical exam; the performance of a CBC, liver function tests, chest diagnostic CT, bone scan, and radiographs of any long or weight-bearing bones that are painful or appear abnormal on bone scan; consideration of diagnostic CT of the abdomen (with or without diagnostic CT of the pelvis) or MRI scan of the abdomen; and biopsy documentation of first recurrence if possible. The panel generally discourages the use of sodium fluoride PET or PET/CT scans for the evaluation of patients with recurrent

Version 2.2015, 03/11/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. MS-44