NCCN Breast Cancer Version 3 . 2014 Clinical Practice Guidelines in Oncology

Breast cancer is the most common malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. The overall management of breast cancer includes the treatment of local disease with surgery, radiation therapy, or both, and the treatment of systemic disease with cytotoxic chemotherapy, endocrine therapy, biologic therapy, or combinations of these. The NCCN Guidelines specific to management of large clinical stage II and III tumors are discussed in this article. These guidelines are the work of the members of the NCCN Breast Cancer Panel. Expert medical clinical judgment is required to apply these guidelines in the context of an individual patient to provide optimal care. Although not stated at every decision point of the guidelines, patient participation in prospective clinical trials is the preferred option of treatment for all stages of breast cancer. (J Natl Compr Canc Netw 2014;12:542–590) NCCN Categories of Evidence and Consensus Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate. Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate. All recommendations are category 2A unless otherwise noted. Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Please Note The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representation or warranties of any kind regarding their content, use, or application and disclaims any responsibility for their applications or use in any way. The full NCCN Guidelines for Breast Cancer are not printed in this issue of JNCCN but can be accessed online at NCCN.org. © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. Disclosures for the NCCN Breast Cancer Panel At the beginning of each NCCN Guidelines panel meeting, panel members review all potential conflicts of interest. NCCN, in keeping with its commitment to public transparency, publishes these disclosures for panel members, staff, and NCCN itself. Individual disclosures for the NCCN Breast Cancer Panel members can be found on page 590. (The most recent version of these guidelines and accompanying disclosures are available on the NCCN Web site at NCCN.org.) These guidelines are also available on the Internet. For the latest update, visit NCCN.org. Breast Cancer NCCN Guidelines® © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 12 Number 4 | April 2014 543 Journal of the National Comprehensive Cancer Network Text cont. on page 556. Pathology Assessment A central component of breast cancer treatment is full knowledge of disease extent and biologic features. These factors contribute to the determination of disease stage, assist in estimating the risk of cancer recurrence, and provide information that predicts response to therapy (eg, estrogen receptor [ER], progesterone receptor [PR], and HER2). These factors are determined through examination of excised tissue and provided in a written pathology report. Accurate pathology reporting requires communication between the clinician and the pathologist regarding relevant patient history, prior breast biopsies, prior irradiation to the chest, pregnancy status, characteristics of the abnormality biopsied (eg, palpable, mammographically detected microcalcifications), clinical state of lymph nodes, presence of inflammatory change or other skin abnormality, and any prior treatment administered (eg, chemotherapy, radiation therapy). The specimens should be oriented for the pathologist, and specific requests for determination of biomarkers should be stated (eg, ER, PR, and HER2 status). Data from both national and local surveys show that as many as 50% of pathology reports for breast cancer are missing some elements critical to patient management.5,6 Significant omissions include failure to orient and report surgical margins and failure to report tumor grade consistently. The College of American Pathologists (CAP) has developed pathology reporting protocols to promote complete and standardized reporting of malignant specimens (www.cap.org). The NCCN Breast NCCN Breast Cancer Panel Members William J. Gradishar, MD/Chair‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Benjamin O. Anderson, MD/Vice-Chair¶ University of Washington/ Seattle Cancer Care Alliance Sarah L. Blair, MD¶ UC San Diego Moores Cancer Center Harold J. Burstein, MD, PhD† Dana-Farber/Brigham and Women’s Cancer Center Amy Cyr, MD¶ Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine Anthony D. Elias, MD† University of Colorado Cancer Center William B. Farrar, MD¶ The Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute Andres Forero, MD‡ University of Alabama at Birmingham Comprehensive Cancer Center Sharon Hermes Giordano, MD, MPH† The University of Texas MD Anderson Cancer Center Lori J. Goldstein, MD† Fox Chase Cancer Center Daniel F. Hayes, MD† University of Michigan Comprehensive Cancer Center Clifford A. Hudis, MD† Memorial Sloan-Kettering Cancer Center Steven J. Isakoff, MD, PhD† Massachusetts General Hospital Cancer Center Britt-Marie E. Ljung, MD≠ UCSF Helen Diller Family Comprehensive Cancer Center P. Kelly Marcom, MD† Duke Cancer Institute Ingrid A. Mayer, MD† Vanderbilt-Ingram Cancer Center Beryl McCormick, MD§ Memorial Sloan-Kettering Cancer Center Robert S. Miller, MD† The Sidney Kimmel Comprehensive Cancer Center at