NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

felt to be standard. Tamoxifen (or an aromatase inhibitor if postmenopausal) should be added for those with hormone

The panel recommends that women with intact uteri who are taking adjuvant tamoxifen should have yearly gynecologic assessments and rapid evaluation of any vaginal spotting that might occur because of the risk of tamoxifen-associated endometrial carcinoma in postmenopausal women. 379 The performance of routine endometrial biopsy or ultrasonography in the asymptomatic woman is not recommended. Neither test has demonstrated utility as a screening test in any population of women. The vast majority of women with tamoxifen-associated uterine carcinoma have early vaginal spotting. If an adjuvant aromatase inhibitor is considered in women with amenorrhea following treatment, baseline levels of estradiol and gonadotropin followed by serial monitoring of these hormones should be performed if endocrine therapy with an aromatase inhibitor is initiated. 309 Bilateral oophorectomy assures postmenopausal status in young women with therapy-induced amenorrhea and may be considered prior to initiating therapy with an aromatase inhibitor in a young woman. Symptom management for women on adjuvant endocrine therapies often requires treatment of hot flashes and the treatment of concurrent depression. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI) has been studied and is an effective intervention in decreasing hot flashes. 380-383 There is evidence suggesting that concomitant use of tamoxifen with certain SSRIs (eg, paroxetine, fluoxetine) may decrease plasma levels of endoxifen, an active metabolite of tamoxifen. 384,385 These SSRIs/SNRIs may interfere with the enzymatic conversion of tamoxifen to endoxifen by inhibiting a particular isoform of CYP2D6 . However, the mild CYP2D6 inhibitors such as citalopram, escitalopram, sertraline, and venlafaxine appear to have no or only minimal effect on tamoxifen metabolism. 309,386,387

receptor-positive tumors, and trastuzumab should be given to those with HER2-positive tumors. Post-treatment follow-up for women with stage III disease is the same as for women with early-stage invasive breast cancer. Post-Therapy Surveillance and Follow-up Post-therapy follow-up is optimally performed by members of the treatment team and includes the performance of regular history/physical examinations every 4 to 6 months for the first 5 years after primary therapy and annually thereafter. Mammography should be performed annually. The routine performance of alkaline phosphatase and liver function tests are not included in the guidelines. 372-374 In addition, the Panel notes no evidence to support the use of “tumor markers” for breast cancer, and routine bone scans, CT scans, MRI scans, PET scans, or ultrasound examinations in the asymptomatic patient provide no advantage in survival or ability to palliate recurrent disease and are, therefore, not recommended. 95,375 The use of dedicated breast MRI may be considered as an option for post-therapy surveillance and follow-up in women at high risk for bilateral disease, such as carriers of BRCA1/2 mutations. Rates of contralateral breast cancer following either breast-conserving therapy or mastectomy have been reported to be increased in women with BRCA1/2 mutations when compared with patients with sporadic breast cancer. 376-378 (see NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian ; NCCN Guidelines for Breast Cancer Screening and Diagnosis ).

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-43