NCCN Revises Breast Cancer Risk Reduction Guideline

02/02/18

The National Comprehensive Cancer Network (NCCN) has updated their guideline for breast cancer risk reduction, including significant changes to the section on components of risk/benefit assessment and counseling.

Throughout the entire guideline, “risk-reduction” has been changed to “risk-reducing.”

In the follow-up section of the risk-reducing intervention algorithm, “Monitor bone density while on aromatase inhibitors” has been added.

The subsequent section for risk-reducing intervention has been changed significantly. Among the removed bullet points are “(Limited to those with known or strongly suspected BRCA1/2 mutations),” “Bilateral salpingo-oophorectomy with peritoneal washings. Pathologic assessment should include fine sectioning of ovaries and fallopian tubes,” and “Bilateral total mastectomy plus reconstruction.” Viewers are now directed to the NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian.

In the section for clinical scenarios and resulting management while on risk-reducing therapy, “Osteopenia/osteoporosis” is new to the page. The corresponding footnote is below: “Weight bearing exercise or use of a bisphosphonate (oral/IV) or denosumab is acceptable to maintain or to improve bone mineral density and reduce risk of fractures in women receiving aromatase inhibitors. Women treated with a bisphosphonate or denosumab should undergo a dental examination with preventive dentistry prior to the initiation of therapy, and should take supplemental calcium and vitamin D.”

Multiple changes were made to the risk-reducing surgery section of the components of risk/benefit assessment and counseling page. Currently, only one bullet remains: “Risk-reducing mastectomy should generally be considered only in women with a genetic mutation conferring a high risk for breast cancer (See NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian, Table on GENE-2), compelling family history, or possibly with prior thoracic RT at < 30 years of age. While this approach has been previously considered for LCIS, the currently preferred approach is risk-reducing therapy. The value of risk-reducing mastectomy in women with deleterious mutations in other genes associated with a two-fold or greater risk for breast cancer (based on large epidemiologic studies) in the absence of a compelling family history of breast cancer is unknown.” All other bullets were removed from this section.

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In the table for breast cancer risk-reducing agents, the second bullet under aromatase inhibitors (exemestane and anastrozole) was revised: “There are retrospective data that AIs can reduce the risk of contralateral breast cancer in BRCA1/2 patients with ER-positive breast cancer who take AIs as adjuvant therapy.”—Zachary Bessette