NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer Updates Updates in Version 1.2015 of the NCCN Guidelines for Breast Cancer from Version 3.2014 include:

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

BINV-7 Changed pN0 "Consider no adjuvant therapy" to "Consider adjuvant chemotherapy with trastuzumab (category 2B). BINV-10 Preoperative systemic therapy guideline, fulfills criteria for breast- conserving surgery except for tumor size. Added a footnote stating; "In cases where breast-conserving surgery may not be possible but patient will need chemotherapy, neoadjuvant treatment remains an acceptable option." BINV-11 • Changed "Desires breast preservation" to "Preoperative systemic therapy" and "Does not desire breast preservation" to "Surgical resection." • Clinically negative axillary lymph nodes, changed axillary "ultrasound" to "imaging." • Moved "clipped with image-detectable marker; positive clipped lymph nodes must be moved if FNA or core biopsy was positive" from the algorithm to a new footnote. "Marking of sampled axillary nodes with a tattoo or clip should be considered to permit verification that the biopsy- positive lymph node has been removed at the time of definitive surgery." • Added two new branch points: "If lymph node FNA or core biopsy negative, SLNB can be performed before or after neoadjuvant systemic therapy" "If lymph node FNA or core biopsy positive, axilla may be restaged after neoadjuvant systemic therapy; ALND should be performed if axilla is clinically positive; SLNB or ALND can be performed if axilla is clinically negative" • Added footnote "ff" stating "Among patients shown to be node-positive prior to neoadjuvant systemic therapy, SLNB has a >10% false-negative rate when performed after neoadjuvant systemic therapy. This rate can be improved by marking biopsied nodes to document their removal, using dual tracer, and by removing more than 2 sentinel nodes." BINV-12 • Clarified footnote "ii" by deleting the term "early stage." The footnote now states: "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." (Also applies to BINV-15 )

BINV-15 • The following statement was added to this page "endocrine therapy alone may be considered for receptor-positive disease in postmenopausal patients." • Added footnote "gg" stating "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." • Added a footnote stating "Administration of all chemotherapy prior to surgery is preferred." BINV-16 • The following changes have been made to the Surveillance/Follow-up recommendations: History and physical exam was changed from "every 4–6 mo for 5 y, then every 12 mo" to "1–4 times per year as clinically appropriate for 5 y, then annually." Added "Educate, monitor, and refer for lymphedema management." Added "In the absence of clinical signs and symptoms suggestive of recurrent disease, there is no indication for laboratory or imaging studies for metastases screening." BINV-17 • Workup, changed "Determination of tumor ER/PR and HER2 status if unknown, originally negative or not overexpressed" to "Determination of tumor ER/PR and HER2 status on metastatic site." Added footnote"rr": "In clinical situations where a biopsy cannot be safely obtained but the clinical evidence is strongly supportive of recurrence, treatment may commence based on the ER/PR/HER2 status of the primary tumor." BINV-18 • Systemic therapy, added "or de novo stage IV" with a new footnote "ww": "The role and timing of surgical removal of the primary in patients presenting with de novo stage IV disease is the subject of ongoing investigations." • Footnote "ss" changed "The optimal schedule and duration of denosumab, zoledronic acid, or pamidronate are unknown" to "The optimal schedule for zoledronic acid is monthly x 12, then quarterly."

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UPDATES-2

Version 2.2015, 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 ® .