NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Invasive Breast Cancer SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR-POSITIVE - HER2-NEGATIVE DISEASE b

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

Consider adjuvant endocrine therapy (category 2B) Adjuvant endocrine therapy w (category 2B) ± adjuvant chemotherapy x,y (category 2B)

pN0

• Tumor ≤0.5 cm or • Microinvasive

pN1mi

Adjuvant endocrine therapy w ± adjuvant chemotherapy x,y (category 1) Adjuvant endocrine therapy w

pT1, pT2, or pT3; and pN0 or pN1mi (≤2 mm axillary node metastasis)

Not done Low

recurrence score (<18) Intermediate recurrence score (18-30) High

See Follow-Up (BINV-16)

Consider 21-gene RT-PCR assay

• Tumor >0.5 cm

Histology: v • Ductal • Lobular • Mixed • Metaplastic

Adjuvant endocrine therapy ± adjuvant chemotherapy w,x,y

recurrence score (≥31) Adjuvant endocrine therapy w + adjuvant chemotherapy x,y (category 1) Adjuvant endocrine therapy + adjuvant chemotherapy w,x,y

Node positive (one or more metastases >2 mm to one or more ipsilateral axillary lymph nodes) bb

See Adjuvant Endocrine Therapy (BINV-J) and Neoadjuvant/Adjuvant Chemotherapy (BINV-K)

b See Principles of HER2 Testing (BINV-A) . v Mixed lobular and ductal carcinoma as well as metaplastic carcinoma should be graded based on the ductal component and treated based on this grading. The metaplastic or mixed component does not alter prognosis. w Evidence supports that the magnitude of benefit from surgical or radiation ovarian ablation in premenopausal women with hormone receptor-positive breast cancer is similar to that achieved with CMF alone. Early evidence suggests similar benefits from ovarian suppression (ie, LHRH agonist) as from ovarian ablation. The combination of ovarian ablation/suppression plus endocrine therapy may be superior to suppression alone. The benefit of ovarian ablation/suppression in premenopausal women who have received adjuvant chemotherapy is uncertain. x Chemotherapy and endocrine therapy used as adjuvant therapy should be given sequentially with endocrine therapy following chemotherapy. Available data suggest that sequential or concurrent endocrine therapy with radiation therapy is acceptable. y There are limited data to make chemotherapy recommendations for those >70 y old. Treatment should be individualized with consideration of comorbid conditions. bb The 21-gene RT-PCR assay recurrence score can be considered in select patients with 1–3 involved ipsilateral axillary lymph nodes to guide the addition of combination chemotherapy to standard hormone therapy. A retrospective analysis of a prospective randomized trial suggests that the test is predictive in this group similar to its performance in node-negative disease.

Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

BINV-6

Version2.2015, 03/11/2015© 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 ® .