Breast Cancer Clinical Practice Guidelines (2019)

National Comprehensive Cancer Network (NCCN)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

June 05, 2019

The updated guidelines on breast cancer were released on May 1, 2019, by the National Comprehensive Cancer Network (NCCN).[1]

Multigene Testing

For patients with hormone receptor (HR)-positive, node-negative, HER2-negative disease and tumors larger than 0.5 cm, clinicians should strongly consider the 21-gene assay.

Early-Stage Breast Cancer in Premenopausal Women

In view of the trials establishing the benefit (in terms of both disease-free survival [DFS] and overall survival [OS]) of ovarian function suppression with tamoxifen and exemestane in premenopausal women with early-stage breast cancer, greater emphasis is placed on adding ovarian function suppression to tamoxifen or exemestane in this population.

HR-Positive Breast Cancer in Postmenopausal Women

Postmenopausal HR-positive breast cancer is most commonly treated with up-front aromatase inhibitor therapy for 5 years. There is high-level evidence for extending therapy for 5 additional years in select patients, but the overall reduction in distant recurrence is 1-1.5%, and longer treatment is associated with greater toxicity. Extended endocrine therapy remains an area of uncertainty and is not currently a strategy that can be recommended for most patients.

Axillary Management of Early-Stage Breast Cancer

Patients with operable disease who will undergo surgery as primary treatment should be stratified according to the presence or absence of clinically positive lymph nodes at diagnosis.

If the patient is clinically node-positive, biopsy of any suspicious lymph nodes should be attempted before surgery is performed. If needle biopsy results are positive and up-front surgery is planned, options that may be considered include (1) axillary lymph node dissection (ALND) and (2) if the patient meets all the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial criteria (T1 or T2 tumor, planned breast-conserving surgery and whole-breast radiation, no preoperative therapy) and has a low tumor burden, sentinel lymph node biopsy (SLNB).

If the patient is clinically node-negative up front, SLNB is typically done first. Patients with one or two positive sentinel nodes are assessed for Z0011 criteria to determine whether completion ALND is indicated.

If the patient is undergoing preoperative therapy first, imaging of the axilla and up-front biopsy of any clinically or radiographically suspicious lymph nodes are recommended. Patients with negative nodes can proceed to SLNB. Those with clinically positive nodes after preoperative therapy should undergo ALND; for those with clinically negative nodes after preoperative therapy, SLNB rather than ALND can be considered in select cases.

Advanced HR-Positive Breast Cancer

For HR-positive disease, recommendations are evolving away from choosing among monotherapy options and toward the concept of partnering endocrine therapy with targeted therapies. Positive findings from pivotal trials led to the recommendation that cyclin-D kinase 4/6 (CDK4/6) inhibitors (palbociclib, ribociclib, and abemaciclib) be added to endocrine therapy as either first-line or second-line treatment; abemaciclib can also be used as monotherapy.

Triple-Negative Metastatic Breast Cancer

For patients with advanced triple-negative breast cancer with BRCA1/2 mutations, poly (ADP-ribose) polymerase (PARP) inhibitors show clear benefit, as do the older platinum agents. Talazoparib is a preferred option, along with olaparib, for patients with HER2-negative disease and germline BRCA1/2 mutations. Optimal sequencing of PARP inhibitors is yet to be determined.

The programmed death ligand 1 (PD-L1) antibody atezolizumab has been found to be beneficial for those with triple-negative breast cancer expressing PD-L1.

For more information, please go to Breast Cancer and Breast Cancer and HER2.

For more Clinical Practice Guidelines, please go to Guidelines.

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