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-19 • Added footnote "yy" to the following nodes: ER-and/or PR positive; HER2 positive Prior endocrine therapy within 1 y – Postmenopausal BINV-B

BINV-F (continued) • Second paragraph, added the following statement "A boost to the tumor bed is recommended in patients at higher risk (age <50 or high-grade disease, or patients with focally positive margins). This can be achieved with brachytherapy or electron beam or photon fields. Typical doses are 10–16 Gy at 2 Gy/fx." BINV-H (2 of 2) • First bullet, added the following statement "Nipple margin assessment is mandatory, and the nipple margin should be clearly designated." BINV-I • Whole Breast Radiation, modified the statement: "The breast should receive a dose of 45–50 Gy in 1.8-2 Gy per 23–25 fractions, or 40–42.5 Gy in 15–16 fractions (short course is preferred)." • Regional Nodal Radiation, replaced "If internal mammary lymph nodes are clinically or pathologically positive, radiation therapy should be given to the internal mammary nodes. Otherwise the treatment to the internal mammary nodes is at the discretion of the treating radiation oncologist" with "Based on the modern post mastectomy radiation randomized trials and other recent studies, consider including the internal mammary lymph nodes when delivering regional nodal irradiation." BINV-J • Added a new footnote for premenopausal at diagnosis stating, "Aromatase inhibitor for 5 y + ovarian suppression may be considered as an alternative option based on SOFT and TEXT clinical trial outcomes." Pagani O, Regan M, Walley B, et al. Adjuvant Exemestane with Ovarian Suppression in Premenopausal Breast Cancer. N Engl J Med 2014; 371:107-118. July 10, 2014DOI: 10.1056/NEJMoa1404037. BINV-K • Other regimens for HER2-negative disease, added "AC (doxorubicin/ cyclophosphamide) every 3 weeks (category 2B)." • Other regimens for HER2-positive disease, added "Docetaxel + cyclophosphamide + trastuzumab." • Updated reference list.

• Clinical Indications and Applications, removed the following bullet: "May be useful to detect additional disease in women with mammographically dense breast, but available data do not show differential detection rates by any subset by breast pattern (breast density) or disease type (eg, DCIS, invasive ductal cancer, invasive lobular cancer)." BINV-C • Deleted "No therapy has been shown to preserve fertility in patients receiving chemotherapy." • Added "Randomized trials have shown that ovarian suppression with GnRH agonist therapy administered during adjuvant chemotherapy in premenopausal women with ER-negative tumors may preserve ovarian function and diminish the lkelihood of chemotherapy-induced amenorrhea." • Added "Smaller historical experiences in patients with ER-positive disease have reported conflicting results with regards to the protective effect of GNRH agonist therapy on fertility." BINV-D • Sentinel node positive: removed "Axillary dissection level I/II" as an option. • Added footnote "4" stating: "For patients with clinically negative axillae who are undergoing mastectomy and for whom radiation therapy is planned, axillary radiation may replace axillary dissection level I/II for regional control of disease." BINV-F • First paragraph, added the following statement "The NCCN Panel accepts the definition of a negative margin as "No ink on the tumor," from the 2014 Society of Surgical Oncology-American Society for Radiation Oncology Consensus Guidelines on Margins." • Added Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014 May 10;32(14):1507-15

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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 ® .