NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

In terms of treatment, breast cancer may be divided into 1) the pure noninvasive carcinomas, which include LCIS and DCIS (stage 0); 2) operable, locoregional invasive carcinoma with or without associated noninvasive carcinoma (clinical stage I, stage II, and some stage IIIA tumors); 3) inoperable locoregional invasive carcinoma with or without associated noninvasive carcinoma (clinical stage IIIB, stage IIIC, and some stage IIIA tumors); and 4) metastatic (stage IV) or recurrent carcinoma. Pure Noninvasive Carcinomas (Stage 0) Both LCIS and DCIS may be difficult to distinguish from atypical hyperplasia or from invasive carcinomas with early invasion. 28,29 Therefore, pathology review of all cases is recommended. Bilateral diagnostic mammography should be performed to identify the presence of multiple primary tumors and to estimate the extent of the noninvasive lesion. Diagnostic evaluation of LCIS is described in the NCCN Guidelines for Breast Screening and Diagnosis . Genetic counseling is recommended if the patient is considered to be at high risk for hereditary breast cancer as defined by the NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian . Testing for genetic mutations without formal genetic counseling is discouraged. The goal of treatment of pure in situ carcinoma is either preventing the occurrence of invasive disease or diagnosing the development of an invasive component when still localized to the breast. Patients with invasive disease, even if microinvasive, on pathology review or during re-excision, mastectomy, or ALN staging should be treated according to the stage-appropriate guideline for invasive carcinoma. Lobular Carcinoma in Situ (Stage 0, Tis, N0, M0)

testing using the IHC method on the same specimen or repeating tests if a new specimen is available. HER2 testing should be performed in laboratories accredited by CAP or another equivalent authority to carry out such testing. Further, these laboratories should have standardized HER2 testing procedures in place, as well as programs to periodically evaluate the proficiency of personnel performing HER2 testing. HER2 test reports should also include information on site of tumor; specimen type; histologic type; fixation method and time; block examined; and details on the HER2 testing method(s) used. Clinicians should be familiar with the significance of these criteria when making clinical recommendations for an individual patient. Treatment Approach Conceptually, the treatment of breast cancer includes the treatment of local disease with surgery, radiation therapy, or both, and the treatment of systemic disease with cytotoxic chemotherapy, endocrine therapy, biologic therapy, or combinations of these. The need for and selection of various local or systemic therapies are based on several prognostic and predictive factors. These factors include tumor histology, clinical and pathologic characteristics of the primary tumor, ALN status, tumor hormone receptor content, tumor HER2 status, multi-gene testing, presence or absence of detectable metastatic disease, patient comorbid conditions, patient age, and menopausal status. Breast cancer does occur in men, and men with breast cancer should be treated similarly to postmenopausal women, except that the use of aromatase inhibitors is ineffective without concomitant suppression of testicular steroidogenesis. 26,27 Patient preference is a major component of the decision-making process, especially in situations in which survival rates are equivalent among the available treatment options.

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-5