NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

breast-conserving therapy with mastectomy in patients with stage I and stage II disease. The 133 (approximately 8%) patients experiencing a local recurrence as an initial event were approximately equally divided between those who had undergone mastectomy and those who had received breast-conserving therapy as initial treatment for breast cancer. Of those in the former group, 51 (76%) were able to undergo radiation therapy with or without surgery as treatment for local disease recurrence. No difference in survival emerged when patients receiving salvage treatment after initial treatment with mastectomy or breast-conserving therapy were compared; approximately 50% of both groups were alive at 10-year follow-up. 407 Mastectomy-treated patients should undergo surgical resection of the local recurrence (if it can be accomplished without heroic surgery) and involved-field radiation therapy to the chest wall and supraclavicular area (if the chest wall was not previously treated or if additional radiation therapy may be safely administered). The use of surgical resection in this setting implies the use of limited excision of disease with the goal of obtaining clear margins of resection. Unresectable chest wall recurrent disease should be treated with radiation therapy if no prior radiation has been given. Women with a local recurrence of disease after initial breast-conserving therapy should undergo a total mastectomy and axillary staging if a level I/II axillary dissection was not previously performed. Limited data suggest that a repeat SLN biopsy following local recurrence of disease may be successfully performed in 80% of women who have previously undergone breast-conserving therapy and sentinel node biopsy. 408 The consensus of the panel is that the preferred surgical approach for most women with a local recurrence following breast-conserving therapy and sentinel node biopsy is mastectomy and a level I/II axillary dissection, although sentinel node

biopsy in lieu of a level I/II axillary dissection can be considered if prior axillary staging was done by sentinel node biopsy only. After local treatment, women with local recurrences only should be considered for limited duration systemic chemotherapy or endocrine therapy similar to that outlined in the adjuvant chemotherapy section. The panel emphasized the importance of individualizing treatment strategies in patients with a recurrence of disease limited to a local site. Management of Stage IV or Recurrent Metastatic Disease The systemic treatment of breast cancer recurrence or stage IV disease prolongs survival and enhances quality of life but is not curative. Therefore, treatments associated with minimal toxicity are preferred. Thus, the use of the minimally toxic endocrine therapies is preferred to the use of cytotoxic therapy whenever reasonable. 409 Guideline Stratification for Therapy in Systemic Disease Patients with recurrence of breast cancer or metastatic breast cancer at diagnosis are initially stratified according to whether bone metastasis is present. These two patient subsets are then stratified further by tumor hormone receptor and HER2 status. Supportive Therapy for Bone Metastases Treatment targeting osteoclast activity is of value in patients with metastatic breast cancer in bone to prevent bone fractures, bone pain requiring radiation therapy, spinal cord compression, and hypercalcemia (skeletal related events; SREs). 410-412 The bisphosphonates zoledronic acid or pamidronate have been used for this purpose, and there is extensive clinical trial support for their efficacy in prevention of SREs (see section below on bisphosphonates). A single, randomized, active, controlled trial in metastatic breast cancer showed equivalency and superiority of time to the occurrence of SRE with denosumab, a fully

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-46