NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

another did not. 80 One systematic review 77 documented breast MRI staging to alter surgical treatment in 7.8% to 33.3% of women. 77 However, no differences in outcome, if any, can be demonstrated in that analysis. Patients should not be denied the option of breast conservation therapy based upon MRI findings alone without tissue sampling. Fertility Numerous epidemiologic studies have demonstrated that child-bearing after treatment for invasive breast cancer does not increase rates of recurrence or death from breast cancer. 81 The offspring of pregnancies after treatment for breast cancer do not have an increased rate of birth defects or other serious childhood illness. However, treatment for breast cancer, especially with cytotoxic agents, may impair fertility. Therefore, it is reasonable and appropriate to consider fertility preservation prior to breast cancer treatment in young women who desire to bear children following breast cancer therapy. 82-86 No high-level evidence demonstrates that ovarian suppression or other interventions decrease the toxicity of cytotoxic chemotherapy on the premenopausal ovary. 87 However, many women, especially those younger than age 35, regain menstrual function within 2 years of completing chemotherapy. 88 Resumption of menses does not necessarily correlate with fertility, and fertility may be preserved without menses. All premenopausal patients should be informed about the potential impact of chemotherapy on fertility and asked about their desire for potential future pregnancies. Should a newly diagnosed premenopausal woman with breast cancer desire to bear children after breast cancer treatment, she should receive consultation with a physician with expertise in fertility prior to the initiation of chemotherapy. 86,89 Multiple factors to consider in making a decision for fertility preservation include

Overall, approximately half of the local recurrences after initial treatment for a pure DCIS are again DCIS, and the others are invasive cancer. Those with local recurrences that are invasive should receive systemic treatment as appropriate for a newly diagnosed invasive breast cancer. Invasive Breast Cancer Stage I, IIA, IIB, or T3N1M0 Invasive Breast Cancer Staging and Workup The recommended workup and staging of invasive breast cancer includes: history and physical exam; a CBC count; liver function tests ; bilateral diagnostic mammography; breast ultrasonography, if necessary; tumor ER and PR determinations; HER2 tumor status determination; and pathology review. 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 . Use of MRI to evaluate women considering breast-conserving therapy is optional. If MRI imaging of the breast is performed, it should be done with a dedicated breast coil, with consultation with the multidisciplinary treatment team, and by a breast imaging team capable of performing MRI-guided biopsy. The limitations of breast MRI include a high percentage of false-positive findings. 75-77 MRI imaging of the breast, therefore, should generally be considered in the staging of breast cancer for patients whose breasts cannot be imaged adequately with mammography and ultrasound (eg, women with very dense breast tissue; women with positive axillary nodal status and occult primary tumor presumed to originate in the breast; to evaluate the chest wall). 78 No randomized, prospective assessment of the utility of MRI in staging or treatment decision making in breast cancer treatment is available. One retrospective study suggested an outcome benefit 79 whereas

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-11