Updated NCCN Guidelines for Breast Cancer Discourages Prophylactic Mastectomy in Women Other Than Those at High Risk
The removal of a noncancerous breast (prophylactic mastectomy) is generally discouraged in women other than those at high risk as stated in the updated National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology™ for Breast Cancer. Other noteworthy updates to the NCCN Guidelines include a new regimen for adjuvant chemotherapy in invasive breast cancer and the option for women with clinically negative lymph nodes to avoid a full axillary lymph node dissection.
October 28, 2009
FORT WASHINGTON, PA — Despite a recent study finding that an increasing number of women who had cancer in one breast are opting to have the other breast removed, the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology™ for Breast Cancer discourages prophylactic mastectomy in women except for those considered high risk. This recommendation is noted in the recently updated NCCN Guidelines for Breast Cancer along with a new regimen for adjuvant chemotherapy and recommendations for utilizing sentinel node mapping and excision in women with clinically negative lymph nodes.
In the updated NCCN Guidelines, it states that prophylactic mastectomy (the removal of a noncancerous breast) contralateral to a known unilateral breast cancer is not recommended except as outlined in the NCCN Guidelines for Genetics/Familial High-Risk Assessment: Breast and Ovarian and the NCCN Guidelines for Breast Cancer Risk Reduction. When prophylactic mastectomy is being considered, the NCCN Guidelines note that the small benefits must be balanced with the risk of recurrent disease from the known breast cancer, the psychological and social issues associated with bilateral mastectomy, and the overall risks of contralateral mastectomy.
The practice of removing noncancerous breasts to reduce the risk or prevent cancer has become increasingly common among women. A study recently published in the journal Cancer found that among women who had cancer in one breast, the number who opted to have the other breast removed, more than doubled from 1995 through 2005 in New York state. However, there is no data to demonstrate that having prophylactic mastectomy actually improves survival.
The NCCN Guidelines Panel suggests that high-risk women considering a prophylatic mastectomy should be evaluated by a multi-disciplinary team and counseled on the risks of the procedure.
Perhaps the most clinically important update to the NCCN Guideline is the removal of the recommendation for a full axillary lymph node dissection as an option for women with clinically negative lymph nodes. The updated NCCN Guidelines now recommend that women with stage one or two invasive breast cancer with clinically negative lymph nodes, undergo sentinel node mapping and excision provided they are being treated by a team of clinicians with experience in sentinel node biopsy.
Sentinel node biopsy is a diagnostic procedure used to determine whether breast cancer has metastasized to axillary lymph nodes (e.g., lymph nodes under the arm). Sentinel node biopsy requires the removal of only a few lymph nodes compared to a full axillary lymph node dissection, and may decrease the risk of lymphedema and pain associated with surgery.
Another important update to the NCCN Guidelines is the addition of a new regimen for adjuvant chemotherapy for invasive breast cancer. The NCCN Guidelines now include FEC [fluorouracil (Adrucil®, Pfizer Inc.) / epirubicin (Ellence®, Pfizer Inc.) / cyclophosphamide (Cytoxan®, Bristol-Myers Squibb Company)] followed by weekly paclitaxel (Taxol®, Bristol-Myers Squibb Company) as an option for adjuvant therapy, treatment given after surgery.
Although the incidence of breast cancer has increased steadily in the United States over the past few decades, breast cancer mortality appears to be declining suggesting a benefit from early detection and more effective treatment.
NCCN Clinical Practice Guidelines in Oncology™ are developed and updated through an evidence-based process with explicit review of the scientific evidence integrated with expert judgment by multidisciplinary panels of physicians from NCCN Member Institutions. The most recent version of this and all the NCCN Guidelines are available free of charge at NCCN.org.
About the National Comprehensive Cancer Network
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 of the world's leading cancer centers, is dedicated to improving the quality and effectiveness of care provided to patients with cancer. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers. The primary goal of all NCCN initiatives is to improve the quality, effectiveness, and efficiency of oncology practice so patients can live better lives. For more information, visit NCCN.org.
The NCCN Member Institutions are:
- Fred & Pamela Buffett Cancer Center
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
- City of Hope Comprehensive Cancer Center
- Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center
- Duke Cancer Institute
- Fox Chase Cancer Center
- Huntsman Cancer Institute at the University of Utah
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
- Mayo Clinic Cancer Center
- Memorial Sloan Kettering Cancer Center
- Moffitt Cancer Center
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
- Roswell Park Cancer Institute
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
- Stanford Cancer Institute
- University of Alabama at Birmingham Comprehensive Cancer Center
- UC San Diego Moores Cancer Center
- UCSF Helen Diller Family Comprehensive Cancer Center
- University of Colorado Cancer Center
- University of Michigan Comprehensive Cancer Center
- The University of Texas MD Anderson Cancer Center
- University of Wisconsin Carbone Cancer Center
- Vanderbilt-Ingram Cancer Center
- Yale Cancer Center/Smilow Cancer Hospital