NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Invasive Breast Cancer PREOPERATIVE SYSTEMIC THERAPY FOR LOCALLY ADVANCED INVASIVE BREAST CANCER (NON-INFLAMMATORY)

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

LOCOREGIONAL TREATMENT

ADJUVANT TREATMENT

Total mastectomy + level l/ll axillary dissection + radiation therapy to chest wall and infraclavicular and supraclavicular nodes (plus internal mammary nodes if involved, strongly consider internal mammary nodes if not clinically involved [category 2B]) ± delayed breast reconstruction n or Consider lumpectomy nn + level l/ll axillary dissection + radiation therapy to breast and infraclavicular and supraclavicular nodes (plus internal mammary nodes if involved) Consider additional systemic chemotherapy and/or preoperative radiation

• Complete planned chemotherapy regimen course if not completed preoperatively plus endocrine treatment if ER-positive and/or PR- positive (sequential chemotherapy followed by endocrine therapy). • Complete up to one year of trastuzumab therapy if HER2- positive (category 1). May be administered concurrently with radiation therapy p and with endocrine therapy if indicated. Response - See above pathway

Response

Preoperative systemic therapy gg,hh,ii,jj (endocrine therapy alone may be considered for receptor-positive disease in postmenopausal patients) kk

See Surveillance/

Follow-up (BINV-16)

No response

Individualized treatment

No response

n See Principles of Breast Reconstruction Following Surgery (BINV-H) . p See Principles of Radiation Therapy (BINV-I) .

gg A number of chemotherapy regimens have activity in the preoperative setting. In general, those chemotherapy regimens recommended in the adjuvant setting may be considered in the preoperative setting. See Neoadjuvant/Adjuvant Chemotherapy (BINV-K) . If treated with endocrine therapy, an aromatase inhibitor is preferred for postmenopausal women. hh Patients with HER2-positive tumors should be treated with preoperative systemic incorporating trastuzumab for at least 9 weeks of preoperative therapy See Neoadjuvant/Adjuvant Chemotherapy (BINV-K) . ii A pertuzumab-containing regimen may be administered preoperatively to patients with greater than or equal to T2 or greater than or equal to N1, HER2-positive breast cancer. jj Admistration of all chemotherapy prior to surgery is preferred. kk See Definition of Menopause (BINV-L) . nn For patients with skin and/or chest wall involvement (T4 non-inflammatory) prior to neoadjuvant therapy, breast conservation may be performed in carefully selected patients based on a multidisciplinary assessment of local recurrence risk. In addition to standard contraindications to breast conservation ( see BINV-G ), exclusion criteria for breast conservation include: inflammatory (T4d) disease before neoadjuvant therapy and incomplete resolution of skin involvement after neoadjuvant therapy.

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-15

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 ® .