Introduction
Methodology
Category, grade | Definition |
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Strength of recommendation | |
A | Good evidence to support a recommendation for use |
B | Moderate evidence to support a recommendation for use |
C | Poor evidence to support a recommendation |
D | Moderate evidence to support a recommendation against use |
E | Good evidence to support a recommendation against use |
Quality of evidence | |
I | Evidence from ≥ 1 properly randomized, controlled trial |
II | Evidence from ≥ 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from > 1 center); from multiple time series; or from dramatic results from uncontrolled experiments |
III | Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees |
Recommendation | Category, grade |
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Diagnosis and initial workup | |
Bilateral mammography and ultrasound of breast and regional lymph nodes in patients with suspected breast cancer | I, A |
Core needle biopsy including evaluation of estrogen and progesterone receptors together with HER2 expression in patients with suspected breast cancer | I, A |
Fine needle aspiration or core biopsy of suspicious lymph nodes | II, A |
Bilateral breast MRI, with histologic confirmation of additional findings, as part of initial staging in patients with confirmed breast cancer, especially in patients with positive axillary nodes and occult primary breast cancer, Paget´s disease of the nipple, lobular carcinoma and multifocal or multicentric lesions | I, B |
Laboratory test as part of initial staging of patients with confirmed breast cancer | III, B |
Additional staging with chest and abdomen CT and bone scan in patients with stage III disease and/or with clinical or laboratory suggesting metastases | III, B |
Additional staging with PET-CT in patients with locally advanced breast cancer | II, A |
Evaluation of cardiac function in patients requiring anthracyclines and/or trastuzumab | I, A |
Surgery | |
Consideration of breast-conserving surgery as first surgical option in stages I–II | I, A |
No indication of additional excision in patients with no ink on invasive tumor or DCIS after breast-conserving surgery | I, A |
Contralateral mastectomy should be offered through an appropriate counseling process in BRCA1/2 mutation carriers | I, A |
Sentinel lymph node (SLN) biopsy in patients with clinically negative axillary nodes | I, A |
Omission of axillary lymph node dissection in patients with stage I–II disease and less than three positive axillary nodes after SLN biopsy and lumpectomy followed by adjuvant systemic therapy and radiotherapy | I, A |
In patients with cN0 tumors, additional treatment of axilla is not necessary if SLNB is negative after neoadjuvant chemotherapy | I, A |
In patients with cN + tumors, if SLNB is negative after neoadjuvant chemotherapy (NAC): | |
ALND should be considered the standard procedure | I, A |
ALND may be omitted in selected cases (pre-treatment marking of involved node, recovery of at least 2 SLNs, double-tracer technique) | II, C |
Adjuvant radiotherapy | |
Hypofractionated schemes are preferred for external beam whole radiation therapy after breast-conserving surgery | I, A |
In elderly patients, the benefit of radiotherapy after breast-conserving surgery for stage I tumors should be assessed individually | I, A |
Nodal (supra-and infra-clavicular) irradiation should be administered in patients with four or more involved nodes after breast-conserving surgery | I, A |
Nodal (supra-and infra-clavicular) irradiation is recommended in patients with one to three involved nodes after breast-conserving surgery | I, B |
In cN0 patients with pT1-2 tumors and positive SLNB, axillary irradiation may be used as an alternative to ALND | I, B |
Chest wall and regional node (supraclavicular and internal mammary) irradiation should be administered in patients with four or more involved nodes, T4 or T3N+ tumors after mastectomy | I, A |
Chest wall irradiation is recommended in patients with close or positive margins after mastectomy | II, A |
Post-mastectomy irradiation should be considered in patients with T1-2 tumors and one to three involved nodes, or in patients with T3N0 tumors, after individually balancing risk factors for recurrence and patient preferences | I, B |
Adjuvant radiotherapy is recommended after NAC in patients with stage III and T3N0 disease, regardless of response to NAC, and in patients with node-positive disease after NACT | I, A |
Adjuvant radiotherapy may be omitted after NAC in patients with stage II (excluding T3N0) who achieve a pCR and do not have additional risk factors for recurrence | I, B |
Decision-making for systemic adjuvant treatment | |
OncotypeDX recurrence score (RS) may be used for prediction of the risk of distant recurrence at 9 years in patients with hormone receptor (HR)-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only | I, A |
OncotypeDX recurrence score (RS) may be used for prediction of the benefit of adjuvant chemotherapy in patients with hormone receptor (HR)-positive and HER2-negative | I, A |
Prosigna risk of distant recurrence score (ROR) may be used for prediction of the risk of distant recurrence at 10 years in patients with HR-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only for 5 years | I, B |
Prosigna risk of distant recurrence score (ROR) may be used for prediction of the risk of late distant recurrence (years 5–10) in patients with HR-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only for 5 years | I, B |
Mammaprint risk score may be used for prediction of the risk of distant recurrence at 5 years in patients with hormone receptor (HR)-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only | I, A |
EndoPredict Epclin score may be used for prediction of the risk of distant recurrence at 10 years in patients with HR-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only for 5 years | I, B |
EndoPredict Epclin score may be used for prediction of the risk of late distant recurrence (years 5–10) in patients with HR-positive and HER2-negative breast cancer treated with adjuvant endocrine therapy-only for 5 years | I, B |
Adjuvant and neoadjuvant systemic treatment of luminal breast cancer | |
Adjuvant endocrine therapy (ET) should be offered to any patient with HR-positive breast cancer | I, A |
Adjuvant ET with tamoxifen for 5 years is recommended as a standard treatment for premenopausal women with HR-positive breast cancer | I, A |
Extended adjuvant ET with tamoxifen up to 10 years should be considered in high-risk patients | I, B |
Adjuvant ET with exemestane plus ovarian function suppression should be offered to high-risk premenopausal breast cancer patients treated with adjuvant chemotherapy or in very young (under 35 years) women. | I, A |
In high-risk patients not suitable or intolerant to aromatase inhibitors, tamoxifen plus ovarian function suppression may be considered as an alternative | II, B |
Adjuvant ET for postmenopausal patients may consist in any of the following alternatives, after considering risk factors and individual preferences: | |
Aromatase inhibitor (AI) during 5 years | I, A |
Tamoxifen for 2–3 years followed by an AI to complete 5 years | I, A |
Tamoxifen for 2–3 years followed by an AI during 5 years | II, B |
Tamoxifen for 4.5–6 years followed by 2.5–5 years of an AI | I, A |
Adjuvant treatment with oral or intravenous bisphosphonates should be considered in postmenopausal patients with breast cancer who are candidates for adjuvant systemic therapy | I, A |
Adjuvant chemotherapy with standard anthracyclines and/or taxane regimens for luminal breast cancer is recommended for tumors defined by either clinical or genomic risk factors: T2-4, axillary node involvement N2-3, extensive LVI, high Ki67, low ER expression, younger age and premenopausal status, and intermediate to high genomic score. | I, A |
NAC is indicated in locally advanced hormone receptor (HR)-positive and HER2-negative breast cancer | I, A |
A sequential regimen of anthracyclines and taxanes is recommended in those patients in which NAC is indicated for hormone receptor (HR)-positive and HER2-negative breast cancer | II, B |
Aromatase inhibitors are preferred over tamoxifen in postmenopausal patients in which neoadjuvant endocrine therapy is indicated for hormone receptor (HR)-positive and HER2-negative breast cancer | I, A |
Neoadjuvant endocrine therapy with AI plus ovarian suppression or with tamoxifen might be considered in selected premenopausal patients in which chemotherapy is not an option | II, D |
Adjuvant and neoadjuvant systemic treatment of HER2 breast cancer | |
Addition of adjuvant trastuzumab to chemotherapy is recommended for HER2-positive breast cancer both in node-positive and in node-negative tumors with a tumor size > 1 cm | I, A |
12-month duration of trastuzumab should be considered standard | I, A |
Addition of adjuvant trastuzumab to chemotherapy should be considered in most cases of node-negative HER2-positive breast cancer with tumor size of 0.5–1.0 cm | II, B |
For adjuvant chemotherapy of HER2-positive breast cancer, AC or EC for 4 cycles followed by 3 months of paclitaxel (P) or docetaxel (D or T) both in combination with trastuzumab (AC/EC → P/D + H) or docetaxel, carboplatin and trastuzumab (TCH) are the preferred regimens | I, A |
In node-negative stage I tumors, an alternative less intense regimen with single-agent paclitaxel and trastuzumab for 12 weeks followed by single-agent trastuzumab (to complete a year) may be considered | II, B |
Adjuvant dual HER2 blockade with trastuzumab and Pertuzumab for 18 cycles may be considered in patients with high-risk (node-positive and/or HR-negative) HER2-positive breast cancer. In patients that have received neoadjuvant treatment, Pertuzumab may be continued after surgery up to 18 cycles | I, B |
Extended adjuvant treatment with neratinib after one year of trastuzumab may be considered in patients with node-positive and HR-positive HER2-positive breast cancer | I, B |
Dual blockade with trastuzumab and pertuzumab and chemotherapy should be considered for the treatment of HER2-positive breast cancer patients who meet criteria for neoadjuvant treatment (> 2 cm tumor size and/or node-positive) | II, B |
Adjuvant and neoadjuvant systemic treatment of triple-negative breast cancer | |
Adjuvant chemotherapy for triple-negative breast cancer should include an anthracycline and a taxane, although the regimen docetaxel-cyclophosphamide might be considered in patients with a high risk for cardiac toxicity | I, B |
No adjuvant chemotherapy is recommended for node-negative pT1a triple-negative breast cancer | III, B |
Adjuvant chemotherapy may be considered for 0.6–1 cm tumors after an adequate individualized balance | III, B |
Neoadjuvant chemotherapy for triple-negative breast cancer should include sequential anthracyclines and taxanes | I, A |
Carboplatin may be considered as part of neoadjuvant chemotherapy for triple-negative breast cancer patients | I, A |
Adjuvant capecitabine for 6-8 cycles should be considered in high-risk triple-negative breast cancer with residual invasive disease at surgery following standard neoadjuvant chemotherapy | I, B |
Follow-up of early breast cancer | |
Breast cancer surveillance is recommended in order to detect breast cancer recurrence and second primary tumors, assess physical and psychosocial long-term effects of breast cancer and its treatment, and promote a healthy lifestyle | I, A |
Healthy lifestyles are recommended to prevent tumor recurrence | II, A |
Early breast cancer follow-up should include regular visits every 3–6 months in the first 2 years, every 6 months from years 3–5 and annually thereafter | III, A |
Annual ipsilateral (after breast-conserving surgery) and/or a contralateral mammography with ultrasound is recommended for follow-up of early breast cancer | II, A |
Diagnosis and initial workup
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Bilateral mammography and ultrasound of the breast and regional lymph nodes [I, A] [4]. Several new techniques such as 3D mammography or 3D ultrasound can increase diagnostic accuracy but are not routinely implemented.
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Core needle biopsy (preferably by ultrasound or stereotactic guidance). The study has to include the evaluation of the estrogen and progesterone receptor and HER2 gene expression [I, A]. Given the high inter-observer variability in the Ki-67 determination, it is important to be careful when using Ki67 to inform the decision-making process [5]. Fine needle aspiration or core biopsy of suspicious lymph nodes is recommended [II, A].
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MRI: is the most sensitive method for breast cancer staging but additional findings must be confirmed histologically due to the high false-positivity rate. Its use is not mandatory [I, B] and should be considered in cases of positive axillary nodes and occult primary breast cancer, Paget´s disease of the nipple, lobular carcinoma and multifocal or multicentric lesions. It is recommended prior and after neoadjuvant treatment to define the extent of disease and monitor the response to treatment [III, A] [6].
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Additional studies: anamnesis with personal and family medical history and complete physical examination. Lab test (complete blood count, liver and renal function, alkaline phosphatase and calcium) are routinely used but do not seem to improve detection of occult metastatic disease [III, B] [7].
Principles of surgery
Recommendations of adjuvant radiotherapy
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Breast-conserving surgery: external beam whole radiation therapy (WBRT). Hypofractionation schemes are preferred [I, A] [17]. If four or more nodes are involved, supra and infraclavicular radiotherapy is recommended [I, A]. In patients with one to three involved nodes after breast-conserving surgery, supra and infraclavicular nodal irradiation is recommended to minimize the risk of recurrence and potentially improve disease-specific survival [I, B] [18]. In addition, in patients with T1-2 tumors and cN0 and sentinel lymph node metastases, axillary irradiation is an alternative comparable to the ALND with less morbidity [I, B] [19].
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Mastectomy: chest wall and regional node irradiation including supraclavicular and internal mammary region is recommended in T4 tumors, node-positive T3 tumors, and if involvement of ≥ 4 axillary lymph nodes [I, A]. In cases of close or positive margins, chest wall irradiation is also recommended [II, A] [18, 20]. T1-2 tumors with one to three involved nodes and T3N0 tumors have an increased risk of locoregional recurrence after mastectomy. Post-mastectomy RT reduces the risk of recurrence and mortality and should be considered in these patients. However, benefit of adjuvant RT can be small in some subgroups of patients and must be discussed based on other risk factors such as grade, age, lymphovascular invasion, receptor status or lack of systemic therapy [I, B] [18, 21]. After neoadjuvant chemotherapy (NAC), irradiation is recommended for stage III disease, regardless of response to NAC, and for node-positive disease after NAC [I, A]. For patients presenting with stage II disease (excluding cT3N0) who achieve a pathologic complete response (pCR), radiotherapy could be omitted unless other risk factors [I, B]. [21‐23].