NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Invasive Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

SYSTEMIC TREATMENT OF RECURRENT OR STAGE IV DISEASE

Initial treatment with lumpectomy + radiation therapy

Total mastectomy + axillary lymph node staging if level l/ll axillary dissection not previously done tt Surgical resection if possible uu Surgical resection if possible + radiation therapy to chest wall and supraclavicular and infraclavicular nodes Surgical resection if possible + radiation therapy if possible vv to chest wall, supraclavicular and infraclavicular nodes, and axilla Radiation therapy if possible vv to chest wall and supraclavicular and infraclavicular nodes Radiation therapy if possible vv to chest wall, supraclavicular and infraclavicular nodes, and internal mammary nodes ER and/or PR positive; HER2 negative b ER and/or PR positive; HER2 positive b ER and PR negative, or ER and/or PR positive and endocrine refractory; HER2 negative b ER/PR negative or ER and/or PR positive and endocrine refractory; HER2 positive b

Local only recurrence

Initial treatment with mastectomy + level l/ll axillary dissection and prior radiation therapy Initial treatment with mastectomy no prior radiation therapy

Consider systemic therapy xx See BINV-J, BINV-K, BINV-O

Axillary recurrence

Regional only or Local and regional recurrence Systemic disease or de novo stage IV ww

Supraclavicular recurrence

Internal mammary node recurrence

Add denosumab, zoledronic acid, or pamidronate ss

Bone disease present

See BINV-19

See BINV-20

Bone disease not present

See BINV-21

b See Principles of HER2 Testing (BINV-A) . ss Denosumab, zoledronic acid, or pamidronate (all with calcium and vitamin D supplementation) should be given (category 1) in addition to chemotherapy or endocrine therapy if bone metastasis is present, expected survival is ≥3 months, and renal function is adequate. Patients should undergo a dental examination with preventive dentistry prior to initiation of this therapy. The optimal schedule for zoledronic acid is monthly x 12, then quarterly. tt In women with a local breast recurrence after breast-conserving surgery who had a prior sentinel node biopsy (SNB), a repeat SNB may be technically possible. The accuracy of repeat SNB is unproven, and the prognostic significance of repeat SNB after mastectomy is unknown and its use is discouraged. uu If not technically resectable, consider systemic therapy to best response, then resect if possible. vv The decision to use radiation therapy to treat locoregional recurrence must factor in any prior radiation to the area and the risk of late normal tissue toxicity from the sum of the prior and planned radiation courses. 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. xx For additional information see the Discussion section (MS-46) .

Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

BINV-18

Version2.2015, 03/11/2015© 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 ® .