National Comprehensive Cancer Network

NCCN Guidelines™ & Clinical Resources

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 7, Number 10 November 2009

• NCCN Clinical Practice Guidelines in Oncology™
• Breast Cancer Screening and Diagnosis
• Special Feature
• Issues of Imatinib and Pregnancy Outcome
• Featured Articles
• Issues of Imatinib and Pregnancy Outcome
• The Sonographic Findings and Differing Clinical Implications of Simple, Complicated, and Complex Breast Cysts
• The Role of MRI in Breast Cancer Screening
• Radiation Therapy and Breast Cancer Risk

NCCN Clinical Practice Guidelines in Oncology™

Breast Cancer Screening and Diagnosis

Women in the United States have an estimated lifetime risk of 12.3% for developing breast cancer (i.e., 1 in 8 women). In 2009, an estimated 194,290 cases of invasive breast cancer (192,370 women and 1919 men) and 62,280 cases of female carcinoma in situ of the breast will be diagnosed in the United States, with 40,610 deaths from invasive breast cancer predicted. However, mortality from breast cancer has decreased slightly, attributed partly to mammographic screening. Breast screening is performed in women without any signs or symptoms of breast cancer so that disease can be detected as early as possible. The components of a breast screening evaluation depend on patient age and other factors, such as medical and family history, and can include breast awareness (i.e., patient familiarity with her breasts), physical examination, risk assessment, screening mammography, and, in selected cases, screening MRI. These practice guidelines were designed to facilitate clinical decision-making. General public and health care providers must be aware that mammography or any other imaging modality is not a stand-alone procedure. Neither the current technology of mammography or other imaging tests nor the subsequent interpretation of these tests is foolproof. Patient concerns and physical findings must be considered along with the results of imaging and histologic assessment.

Special Feature

Issues of Imatinib and Pregnancy Outcome
Jane Apperley MD, FRCP, FRCPath

The use of the tyrosine kinase inhibitors (TKIs) in the management of chronic myelogenous leukemia (CML) has changed the natural course of the disease to such an extent that considerations regarding quality of life have become almost as important as those of preservation of life. For many patients, one of the clearest indications of good quality of life is the ability to conceive children and raise a family. Physicians caring for patients with CML are not infrequently asked for advice regarding the need for or appropriateness of stopping treatment to conceive. The introduction of TKIs into clinical practice now offers most patients with CML lengthy remissions and the possibility of normal life expectancies. These improved survivals have resulted in the need to address issues relating to quality of life, including fertility and procreation. Treatment may require lifelong daily therapy with drugs that might inhibit proteins essential to gonadal function, implantation, and embryogenesis. Although most patients with CML experience prolonged remissions while taking a TKI, approximately 20% might require alternative therapies, including allogeneic stem cell transplantation. Because identifying these individuals before treatment is impossible, future fertility must be considered at diagnosis in all patients of child-bearing age.

Featured Articles

The Sonographic Findings and Differing Clinical Implications of Simple, Complicated, and Complex Breast Cysts
John G. Huff, MD

Although palpable and mammographic breast masses are common, and frequently reflect underlying fibrocystic change, they must be distinguished from breast malignancy. Clinical characterization of these masses is often unreliable, and mammographic appearances alone cannot distinguish between those that are solid and those that are cystic. Sonography is an important adjunct to characterize these abnormalities further. Management of solid masses is well established, but overlap in appearance of cystic lesions has led to variability in reporting and management. With current high-resolution ultrasound, specific observations can accurately characterize most cystic masses, thereby facilitating management decisions.

The Role of MRI in Breast Cancer Screening
Constance D. Lehman, MD, PhD, and Robert A. Smith, PhD

The 2009 NCCN Clinical Practice Guidelines in Oncology for breast cancer screening and diagnosis include significant updates for the role of MRI in screening women at increased risk for breast cancer. The NCCN now recommends considering breast MRI as an adjunct to annual mammography and clinical breast examination for women who have a BRCA1 or -2 mutation or a first-degree relative who has a BRCA1 or -2 mutation but have not undergone genetic testing themselves; those with a lifetime risk of 20% or greater as defined by models that are largely dependent on family history; and those with a history of lobular carcinoma in situ. MRI is also recommended for patients who underwent radiation treatment to the chest between 10 and 30 years of age, and in those who carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni, Cowden, and Bannahyan-Riley-Ruvalcaba syndromes). MRI is specifically not recommended for screening women at average risk for breast cancer. This article describes the peer-reviewed, published clinical research trials evaluating breast MRI in high- risk patients, on which the NCCN guidelines were based, and provides suggestions for future research.

Radiation Therapy and Breast Cancer Risk
Andrea K. Ng, MD, MPH, and Lois B. Travis, MD, ScD

Exposure to ionizing radiation has clearly been established as a risk factor for the development of breast cancer. Much data on the relationship between radiation exposures and subsequent breast cancer are derived from atomic bomb survivors and women who received medical exposures either for diagnostic or therapeutic purposes. Although these populations differ in background breast cancer risks and the dose, quality, and timing of radiation, consistent findings include an increased risk with younger age at exposure, long latency to breast cancer development, and increasing risk with increasing radiation dose. Although therapeutic radiation is rarely used to treat benign conditions, it remains an important and effective treatment modality for a wide range of cancers. Increased knowledge of radiation-related breast cancer and modifying influences plays an important role in guiding the initial treatment approach for young women and optimizing long-term follow-up care.