NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

patient preference, the age of the woman, risk of premature ovarian failure based upon anticipated chemotherapy, and length of optimal endocrine therapy. It is important for fetal safety that women do not become pregnant during breast cancer treatment. Also see NCCN Guidelines for Adolescent and Young Adult Oncology . Additional Workup for Stage I-IIB Disease For patients with stage I-IIB disease, additional tests may be considered based on the signs and symptoms. A bone scan is indicated for patients presenting with localized bone pain or elevated alkaline phosphatase. If pulmonary symptoms are present, chest diagnostic CT is indicated. Abdominal imaging using diagnostic CT or MRI is indicated if the patient has elevated alkaline phosphatase, abnormal results on liver function tests, abdominal symptoms, or abnormal physical examination of the abdomen or pelvis. These studies are not indicated in patients with stage I disease without signs/symptoms of metastatic disease, nor are they needed in many other patients with early-stage breast cancer. 90 These recommendations are supported by a study evaluating patients with newly diagnosed breast cancer by bone scan, liver ultrasonography, and chest radiography. 91 Metastases were identified by bone scan in 5.1%, 5.6%, and 14% of patients with stage I, II, and III disease, respectively, and no evidence of metastasis was detected by liver ultrasonography or chest radiography in patients with stage I or II disease. 91 The NCCN Panel recommends against the use of PET or PET/CT scanning in the staging of these early-stage patients. The recommendation against the use of PET scanning is supported by the high false-negative rate in the detection of lesions that are small (<1 cm) and/or low grade, the low sensitivity for detection of axillary nodal metastases, the low prior probability of these patients having detectable metastatic disease, and the high rate of false-positive scans. 92-97

Additional Workup for Stage IIIA (T3, NI, MO) Disease For patients with clinical stage IIIA (T3, N1, M0) disease, additional staging studies including bone scan or sodium fluoride PET scan (category 2B), abdominal imaging using diagnostic CT or MRI, and chest imaging using diagnostic CT should be considered. Ultrasound is an alternative when diagnostic CT or MRI is unavailable. Fluorodeoxyglucose (FDG) PET scan is optional (category 2B). FDG PET scan can be considered at the same time as diagnostic CT. If FDG PET and diagnostic CT are performed and both clearly indicate bone metastases, bone scan or sodium fluoride PET/CT may not be needed. PET/CT scanning is discussed in detail under the section titled Stage III Invasive Breast Cancer . Locoregional Treatment Several randomized trials document that mastectomy with ALN dissection is equivalent to breast-conserving therapy with lumpectomy, axillary dissection, and whole breast irradiation, as primary breast treatment for the majority of women with stage I and stage II breast cancers (category 1). 98-101 The panel recommends whole breast irradiation to include the majority of the breast tissue; breast irradiation should be performed following CT-based treatment planning to limit irradiation exposure of the heart and lungs, and to assure adequate coverage of the primary tumor and surgical site. Tissue wedging, forward planning with segments (step and shoot), or intensity-modulated radiation therapy (IMRT) is recommended. 102 Dose/fraction schedules of either 50 Gy in 25 fractions over 35 days or 42.5 Gy in 16 fractions over 22 days have been prospectively evaluated and are comparable with respect to DFS and OS in a study of women with node-negative, early-stage breast cancer with a median follow-up of 69 months. 103,104

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-12