NCCN breast cancer 2015 edition guide update third

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Updates in Version 3.2015 of Guidelines for Cancer from Version the 2.2015 include: NCCN (Breast)2015 third edition of breast cancer NCCN gu


Updates in Version 3.2015 of Guidelines for Cancer from Version the 2.2015 include: NCCN (Breast)

2015 third edition of breast cancer NCCN guide from the 2015 edition of the update includes second:


The Discussion section has been updated to relect the changes in the algorithm. Updates in Version of the NCCN Guidelines for Breast 2.2015 Cancer from Version 1.2015 include:

The discussion section has been updated to reflect changes in the work steps.

2015 second edition of breast cancer NCCN guide from the 2015 edition of the update includes first:


The following sentence has been removed from the second paragraph: " This can be achieved with; brachytherapy or electron beam or photon ields."

The following sentence has been deleted from the second paragraph: "this can be done by brachytherapy or electron beam or photon field at."



Changed " Focally positive" to " Diffusely positive pathologic margins."

"Was changed to" positive "pathological diffuse positive edge."


- Changed page heading from " Subsequent Endocrine Therapy for Systemic; Disease" to " Endocrine Therapy for Recurrent or Stage IV Disease."

- Added palbociclib as a therapuetic option + letrozole for postmenopausal patients with ER-positive, HER2-negative metastatic breast cancer.

- Added the following footnote: " Palbociclib in combination with letrozole; may be considered as a treatment option for irst-line therapy for postmenopausal patients with ER-positive, HER2-negative metastatic breast cancer."


The page title from "for systemic disease following endocrine therapy" changed to "for recurrent or stage IV disease of endocrine therapy."

- for postmenopausal ER positive and HER2 negative patients with metastatic breast cancer increased in Malibu Prabhu + letrozole as a treatment option.

- added the following footnote: "for breast cancer patients treated with first-line Prabhu Malibu ER positive and HER2 negative transfer after menopause and letrozole can be considered as a treatment option."

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


Modiied footnote " h" stating; Complete axillary lymph node dissection should not be performed in the absence of evidence of invasive cancer or proven axillary metastatic disease in women with apparent pure DCIS.

However, a small of patients apparent DCIS be found have invasive cancer at the time of their deinitive surgical to procedure. proportion pure with

Therefore, the performance of a sentinel lymph node procedure should be strongly considered if the patient with apparent pure DCIS is to be treated with mastectomy or with excision in an anatomic location compromising the performance of a future sentinel lymph node procedure.

2015 first edition of breast cancer NCCN guide from the 2014 edition of the update includes third:


- modify footnote "H" statements on the surface of pure ductal carcinoma in situ in women without proof or evidence of tumor invasion and axillary metastatic disease should be performed under the condition of complete axillary node dissection. However, a small number of patients with simple ductal carcinoma in situ may be found to have aggressive tumors at the end of surgery. Therefore, if only on the surface of ductal carcinoma in situ for mastectomy or anatomic resection of the affected area in sentinel lymph node biopsy in patients should be carefully considered for sentinel lymph node biopsy.


- Modiied the statement " Radiation therapy should follow chemotherapy when; chemotherapy is indicated" to " It is common for radiation therapy to indicated." follow chemotherapy when chemotherapy is;


"When there are indications of chemotherapy radiotherapy chemotherapy should be revised as" behind "statements when there are indications of chemotherapy radiotherapy chemotherapy is usually in the back."


Changed " close margins" to " negative margins but< mm." 1;

- Negative axillary nodes and tumor cm and margins = 5 mm = 1, " No radiation therapy" added a footnote stating: " Postmastectomy radiation therapy may be; considered for patients with multiple high-risk recurrence factors."


"Close to the edge" changed to "negative margin but less than 1mm."

The negative axillary lymph nodes and tumors less than 5cm and the edge is larger than 1mm, without radiotherapy added a footnote: "for having multiple factors can be considered in patients with high risk of recurrence after mastectomy radiotherapy."


Changed pN0 " Consider adjuvant endocrine therapy" to " Consider adjuvant endocrine therapy chemotherapy with trastuzumab + adjuvant (category 2B.");

Added footnote " aa" stating " A pertuzumab-containing regimen can be administered to patients with greater than or equal to T2 or greater than or equal to N1, HER2-positive, early-stage breast cancer." (Also applies to BINV-7);


PN0 - "consider adjuvant endocrine therapy" changed to "consider adjuvant endocrine therapy + chemotherapy plus trastuzumab (2B)."

- increase the footnote "AA" explanation "for more than T2 or more than N1, HER2 positive early breast cancer patients can be given a perjeta scheme." (also applicable to BINV-7)


Added footnote " bb" stating " The 21-gene RT-PCR assay recurrence score can be considered in select patients with 1 involved ipsilateral axillary "C3 lymph nodes to guide the additon of combination chemotherapy to standard hormone therapy.

A retrospective analysis a randomized trial that test is predictive in this group similar to its performance in the node-negative disease." of suggests prospective;


The increase of "BB" that "in the footnotes of selective 1-3 involved ipsilateral axillary lymph nodes in patients with 21- gene RT-PCR analysis to guide the recurrence score added combined with chemotherapy in hormone therapy is considered standard.

A retrospective analysis of a prospective randomized trial suggested that the trial was similar in both the group and the lymph node negative group."


Changed pN0 " Consider adjuvant therapy" to " Consider adjuvant with trastuzumab (category 2B) in


PN0 "without adjuvant therapy" changed to "consider adjuvant chemotherapy with trastuzumab (2B)."


Preoperative systemic therapy guideline, fulills for breast- surgery except for tumor criteria conserving size.

Added a footnote stating; In cases where surgery not be possible patient need chemotherapy will, neoadjuvant treatment an remains acceptable option." but " may;


Preoperative treatment guidelines, in addition to the size of the tumor to meet the standards of breast conserving surgery.

Added a footnote: "if it is not suitable for breast conserving surgery, but patients wish to require chemotherapy, neoadjuvant therapy is still an acceptable option."


- 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 axillary with a or should considered to permit veriication that biopsy- positive lymph node has been removed the at the time of nodes deinitive sampled surgery." be clip;

Added two - new branch points:

The " If lymph node FNA or; core biopsy negative, SLNB can be performed before or after neoadjuvant systemic therapy"

The " 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 > false-negative rate when performed after 10%; neoadjuvant systemic therapy.

This rate can improved marking biopsied to their removal document, using dual tracer, and by more than 2 sentinel nodes." nodes by (removing);


"Conserving desire" changed to "preoperative treatment" and "does not require breast conserving surgery" changed to "."

The clinical axillary lymph node negative axillary "ultrasound" changed to "image."

"The image of the clips can be detected retained; if the fine needle aspiration (FNA) or core needle biopsy to remove positive positive lymph node from the clip marker" steps to move to a new footnote.

"The use of a needle or a clamp for the sampling of axillary lymph nodes should try to confirm that the biopsy positive lymph nodes have been removed during a radical operation."

- added two new bifurcation point:

^ "if the lymph node needle biopsy or core needle biopsy negative sentinel lymph node biopsy can be implemented before or after neoadjuvant treatment"

^ "if the lymph node needle biopsy or core needle biopsy is positive, can be in the neoadjuvant systemic therapy after re staging axillary axillary; if clinically positive axillary lymph node dissection should be performed; if the clinical implementation of negative axillary sentinel lymph node biopsy or axillary lymph node dissection"

The increase of "FF" statements "that footnote before the new auxiliary system for the treatment of lymph node positive patients, the false negative rate of > when the implementation of sentinel lymph node biopsy after neoadjuvant treatment system; 10%. It is possible to improve the ratio by using a double tracer labeled biopsy of the lymph node to demonstrate that it has been removed and that more than two signal nodes have been removed."


Clariied 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);


The term "early" made by deleting "II" clear footnote. The current state of the footnote: "for more than T2 or more than N1, HER2 positive breast cancer patients can be given before operation included perjeta scheme." (also applicable to 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 recommended the adjuvant may be in considered the preoperative setting. in setting regimens

See Neoadjuvant/Adjuvant Chemotherapy (BINV-K)

If treated with therapy, an aromatase is preferred for postmenopausal women." inhibitor endocrine;

- Added a footnote stating " Administration of all chemotherapy prior to; surgery is preferred."


- this page includes the following statements for receptor positive postmenopausal patients can consider only endocrine therapy."

- added a footnote "GG" statements "are effective in the preoperative condition of many chemotherapy. Under normal circumstances, preoperative chemotherapy regimens may be considered in adjuvant therapy. The new adjuvant chemotherapy and adjuvant chemotherapy (BINV-K). If the use of endocrine therapy for menopausal women preferred an aromatase inhibitor."

- added a footnote "all give preferred preoperative chemotherapy."


The following changes have been made to the Surveillance/Follow-up recommendations:

History and physical exam was changed "from " every" C6 Mo for 4; y 5, then every 12 mo" to " times per year 1 "C4 as clinically appropriate for y 5, then annually."

The Added " Educate, monitor, and; refer for lymphedema management."

The 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."


- for the monitoring / follow-up recommendation has made the following changes:

The history and physical examination from 4-6 per month for the 1 time in 5 consecutive years, then every December 1 "changed to" 1-4 times per year for clinical reasonable for 5 consecutive years, then 1 times a year."

The increase of "education, monitoring and management about lymphedema."

The increase in clinical symptoms and signs of no relapse case of no metastasis screening laboratory or imaging indications."


- 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."


- check, if the determination of the unknown, ER/PR and HER2 state of the original tumor negative or no expression "changed to" ER/PR and HER2 determination of tumor metastases."

Added footnote "RR": "where the site is not safe for biopsy, but the clinical evidence strongly supports the recurrence of the clinical condition, the ER/PR/HER2 can be treated according to the primary tumor."


- 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."


The treatment system, "or stage IV" add a new footnote "WW": "the time and position of disease stage IV patients re resection of the primary tumor is an ongoing research topic."

The footnote "SS" "denosumab, zoledronic acid or pamidronate optimal dosing regimen and duration is unknown" change to "zoledronic acid optimal dosing regimen is 12 * 1 times a month, then every quarter of 1."


Added footnote " yy" to; the following nodes:

The ER-and/or PR positive; HER2 positive

The Prior endocrine therapy within 1 y C Postmenopausal.


The following nodes added a footnote "yy":

The ER and / or PR positive HER2 positive;

The past 1 years in endocrine therapy in postmenopausal women


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)."


The clinical indications and application, remove the following items: "in breast photography showed dense breast in women for detection of other diseases may be useful, but according to the existing data show that the breast structure (breast density) or disease types (such as ductal carcinoma in situ and invasive ductal carcinoma, invasive lobular carcinoma) any subtype detection rate have no difference."


- 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 conlicting results with regards to the protective effect of GNRH agonist therapy on fertility."


Delete - "no proven treatment can protect fertility in patients undergoing chemotherapy."

The increase of "randomized trials have demonstrated gonadotropin-releasing hormone agonist in the treatment of ovarian suppression can protect ovarian function and reduce the possibility of chemotherapy-induced amenorrhea in premenopausal women with ER negative tumors during chemotherapy."

- added "little history experience in patients with ER positive disease has been reported for GnRH agonist treatment on fertility protection showed inconsistent results."


- 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."


The sentinel lymph node positive: Remove "I / II axillary dissection" as an option.

- added a footnote "4": "for a mastectomy and radiotherapy for patients with clinically negative axillary, axillary irradiation can replace axillary dissection for Grade 1 / 2 regional disease control."


- First paragraph, added the following statement " The NCCN Panel accepts the; deinition of a negative margin as " No ink on the; tumor, " from the of Surgical Oncology-American Society 2014 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 10; 32 (14): 1507-15 (May)

- 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 with or electron beam or photon achieved brachytherapy ields.

Typical doses are C16 Gy at 2 Gy/fx." 10;

- First bullet, added the following statement " Nipple margin assessment is; mandatory and, the nipple margin should be clearly designated."


The first section, added the following description "NCCN group accepted definition of negative margin for" no ink in the tumor, "from the 2014 Surgical Oncology Association of the United States on the edge of the Radiation Oncology consensus guidelines."

The second section, add the following instructions "in higher risk patients (age < 50 years old or high grade disease or lesions in patients with positive margins) proposed boost to the tumor bed. This can be achieved by close proximity or electron beam or photon fields. The typical dose is 10-16Gy 2Gy/fx."

The first item, add the following instructions "nipple edge assessment is mandatory, and should clearly indicate the edge of the nipple."


Whole Breast Radiation, modiied the statement: " The breast should receive a; dose of Gy in 1.8-2 Gy 45 "C50 per 23" C25 fractions or "C42.5 Gy 40" C16 in 15 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."


The whole breast irradiation, modify the description: "breast should receive a dose of 45-50Gy, 1.8-2Gy/fr, 23-25fr, or 40-42.5Gy/15-16fr (preferred short course)."

Regional lymph node - irradiation, replace if internal mammary lymph node positive or clinical pathology, internal mammary lymph nodes should be given radiotherapy. Otherwise, for the treatment of internal mammary lymph node radiotherapy according to expert judgment "to" according to modern postmastectomy irradiation of randomized trials and other recent studies, when treated with regional lymph node irradiation including internal mammary lymph node."


Added a new footnote for premenopausal at diagnosis stating " Aromatase inhibitor for 5; y suppression may be considered + ovarian as an alternative option based on SOFT and TEXT clinical trial outcomes."

Pagani O, Regan M, Walley B, et al. Exemestane Ovarian in Premenopausal Cancer. Engl J Med 2014, 371:107-118. July 10, 2014DOI: 10.1056/NEJMoa1404037., Breast, Adjuvant, Suppression, N


At the time of diagnosis for early menopause - who added a new footnote, "according to the SOFT and TEXT results of clinical trials of aromatase inhibitors can be considered 5 years + ovarian suppression as an alternative."

Pagani O, Regan M, Walley B, et al. exemestane combined with ovarian suppression in adjuvant treatment of premenopausal breast cancer. N Engl Med 2014; 371:107-118. July 10, 2014DOI: 10.1056/NEJMoa1404037., J


- 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.


The scheme for other HER2 negative disease, "added AC (doxorubicin / cyclophosphamide) q3w (2B)."

- for the other scheme of HER2 positive disease, increased "docetaxel + cyclophosphamide + trastuzumab."

The updated reference list.

BINV-N (1 of)

- Added the following to footnote" 4" " Patients previously treated: with chemotherapy plus trastuzumab in the absence of pertuzumab in the metastatic setting, may be considered for one line of therapy including both trastuzumab plus pertuzumab in combination with or without cytotoxic therapy (such as vinorelbine or taxane).

Further research is to the ideal strategy for sequencing anti-HER2 needed determine therapy."

- Modiied dose schedule for docetaxel; " mg/m 35 IV weekly for 6 wks followed by a 2-week rest, then repeat."

- Modiied dose schedule for FAC chemotherapy; for " cycled; every 21 days" removed " for 6 cycles."

- Added reference

Rivera E, Mejia JA, Arun BJ, et al. Phase comparing the use of 3 study docetaxel on an every-3-week versus weekly schedule in the treatment of metastatic breast cancer. Cancer 2008 Apr 1; 112 (7): 1455- 61

Added reference to support docetaxel/capecitabine chemotherapy combination;

Mavroudis D, Papakotoulas P, Ardavanis A, et al. Randomized phase III trial comparing docetaxel plus epirubicin versus docetaxel plus capecitabine as irst-line treatment in women with advanced breast cancer. Ann Oncol 21:48 (2010).

BINV-N (1/7)

The footnote "4" added: previous chemotherapy plus trastuzumab in patients without metastatic gabha trastuzumab therapy can be considered first-line therapy, including trastuzumab gabha trastuzumab combined with or without cytotoxic drugs (such as Changchun vinorelbine or taxanes). Further studies are needed to determine the optimal order strategy for anti HER2 therapy.

The adjustment of the docetaxel regimen; "35mg/ ivqw * 6 square meters and then rest for 2 weeks, and then repeat. "

The adjusted FAC chemotherapy regimen; for "repeat" every 21 days removed "6 cycle."

The increase of reference

Rivera E, Mejia JA, Arun BJ, et al. docetaxel every 3 weeks 1 times a week and the application in the treatment of metastatic breast cancer 3 control study. Cancer 2008 Apr 1; 112 (7): 1455-

- added support for docetaxel and capecitabine chemotherapy combined reference; Mavroudis D, Papakotoulas P, Ardavanis A, et al. docetaxel table randomized controlled phase III trials doxorubicin and docetaxel plus capecitabine as first-line treatment for women with advanced breast cancer. Ann Oncol 21:48 (2010)


Added footnote " d" to; wide excision without axillary staging:

There are no randomized supporting the of radiation treatment with phyllodes prospective use data tumors.

However, in the setting where additional recurrence would create signiicant morbidity (eg chest wall recurrence following mastectomy radiation therapy may), be considered following the same principles that are applied to the treatment of soft tissue sarcoma.


- no axillary lymph node staging of wide excision adds footnote "d": no prospective randomized data support for the treatment of cystosarcoma phyllodes of the use of radiotherapy. However, in other relapse would have significant morbidity situations (e.g. breast resection of chest wall recurrence), radiotherapy can be considered to follow the same principle that is used in the treatment of soft tissue sarcoma.


Added the - following treatment options:

Lumpectomy including NAC with whole / Central breast radiation therapy or C

"Total mastectomy + sentinel node biopsy with or without breast reconstruction or

The Central lumpectomy including NAC node biopsy without radiation + sentinel therapy (category 2B)

Removed - the following footnotes:

"" With Paget" s disease; and no associated peripheral cancer, or with associated ER-positive DCIS consider tamoxifen mg per day for 5 years." 20;

The " With associated invasive breast; cancer treat, with appropriate systemic adjuvant therapy."


The increased following treatment options:

The center of breast lumpectomy including the nipple areola complex combined with whole breast radiotherapy or

The whole breast biopsy + breast reconstruction surgery or sentinel lymph node.

The center of breast tumor excision surgery including the nipple areola complex + sentinel lymph node biopsy did not radiotherapy (2B)

Delete the following footnote:

Those related to peripheral tumors and no eczematoid carcinoma or ER positive catheter associated carcinoma in situ, consider 20mg/d * 5 years of tamoxifen.

Long for invasive breast cancer, given systemic adjuvant treatment appropriate to deal with.


Modiied footnote " c": replaced; " trastuzumab" with " anti-HER2 therapy."


- modify footnote "C": "anti HER2 therapy" replace "trastuzumab".


Footnote " a" the following statement: removed " and with a palpable border... To erythema."

Footnote " j" is; new to the page " A pertuzumab-containing regimen may be; administered preoperatively to patients with HER2-positive IBC."


The footnote "a": delete the following instructions

"...... And there's a touch of red border."

- "J" is a new footnote for the page

For patients with HER2 positive inflammatory breast cancer, preoperative administration of the inclusion of trastuzumab.

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