NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

discordance rates are in the range of 3.4% to 60% for ER negative to ER positive; 7.2% to 31% for ER positive to ER negative; and 0.7% to 11% for HER2. 397-405 The NCCN Panel recommends that re-testing the receptor status of recurrent disease be performed, especially in cases when it was previously unknown, originally negative, or not overexpressed. For patients with clinical courses consistent with hormone receptor–positive breast cancer, or with prior positive hormone receptor results, the panel has noted that a course of endocrine therapy is reasonable, regardless of whether the receptor assay is repeated or the result of the most recent hormone receptor assay. 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 . Management of Local Disease Only Patients with local recurrence only are divided into 3 groups: those who had been treated initially by mastectomy alone, those who had been treated initially by mastectomy with radiation therapy, and those who had received breast-conserving therapy. In one retrospective study of local recurrence patterns in women with breast cancer who had undergone mastectomy and adjuvant chemotherapy without radiation therapy, the most common sites of local recurrence were at the chest wall and the supraclavicular lymph nodes. 406 The recommendations for treatment of the population of patients experiencing a local recurrence only are supported by analyses of a combined database of patients from the EORTC 10801 and Danish Breast Cancer Group 82TM trials. The analyses compared

disease, except in those situations where other staging studies are equivocal or suspicious . There is limited evidence (mostly from retrospective studies) to support the use of PET/CT scanning to guide treatment planning through determination of the extent of disease in select patients with recurrent or metastatic disease. 95,96,393,394 The Panel considers biopsy of equivocal or suspicious sites to be more likely than PET/CT scanning to provide accurate staging information in this population of patients. The consensus of the Panel is that FDG PET/CT is optional (category 2B) and most helpful in situations where standard imaging results are equivocal or suspicious. The NCCN Panel recommends bone scan or sodium fluoride PET/CT to detect bone metastases (category 2B). However, if the FDG PET results clearly indicate bone metastasis, these scans can be omitted. The NCCN Panel recommends that metastatic disease at presentation or first recurrence of disease should be biopsied as a part of the workup for patients with recurrent or stage IV disease. This ensures accurate determination of metastatic/recurrent disease and tumor histology, and allows for biomarker determination and selection of appropriate treatment. Determination of hormone receptor status (ER and PR) and HER2 status should be repeated in all cases when diagnostic tissue is obtained. ER and PR assays may be falsely negative or falsely positive, and there may be discordance between the primary and metastatic tumors . 395,396 The reasons for the discordance may relate to change in biology of disease, differential effect of prior treatment on clonal subsets, tumor heterogeneity, or imperfect accuracy and reproducibility of assays. 396 Discordance between the receptor status of primary and recurrent disease has been reported in a number of studies. The

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