NCCN Updates Clinical Practice Guidelines for Breast Cancer Screening, Diagnosis

05/07/18

The National Comprehensive Cancer Network (NCCN) has released new guidelines for screening follow-up, ultrasound findings, and other breast cancer considerations.

In the section for screening follow-up, the guidelines recommend risk reduction strategies for women who have a lifetime risk of greater than 20% as defined by models that are largely dependent on family history. For patients aged at least 25 years receiving annual screening mammogram and annual breast MRI, the guidelines recommend beginning 10 years after radiation therapy but not prior to age 30 years.

There is a new section for “Axillary mass” and an accompanying algorithm for “Recommendations for Follow-Up of Axillary Mass” under symptoms during clinical encounter.

In the section for ultrasound finding/palpable mass under suspected complicated cysts, there is now an added recommendation for “Confirmed complicated cyst with visible mobility of internal components.”

An added recommendation was given to the aspirate finding/palpable mass section: “Mass resolves and, bloody aspirate not felt to be traumatic.”

Multiple revisions were made to the section for breast screening considerations. “Hand-held or automated ultrasound can increase cancer detection, but may increase recall and benign breast biopsies” is new to the page. Another new consideration to the page reads as follows: “Current evidence does not support the routine use of molecular imaging (eg, breast specific gamma imaging, sestamibi scan, or positron emission mammography) as screening procedures, but there is emerging evidence that these tests may improve detection of early breast cancers among women with mammographically dense breast; however, the whole radiation therapy effective dose with these tests is between 20-30 times higher than that of mammography.”

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For recommended MRI screening (based on evidence), changes were made for untested patients who are a first-degree relative of a BRCA carrier: “Encourage genetic testing before MRI. For individuals with a genetic mutation, see the NCCN Guidelines for Genetic/Familial High-Risk Assessment Breast and Ovarian.” Additionally, the guidelines recommend encouraging genetic testing for first-degree relatives or MRI for those who decline testing.

“Li-Fraumeni syndrome and first-degree relatives,” “Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives,” and “greater than 20% risk of breast cancer based on gene and or risk level – ATM, CDH-1, CHEK2, NF1, NBN, PALB2, PTEN, STK11, TP53” have been removed from the list of characteristics that warrant MRI screening because for individuals with genetic mutations, the guidelines now recommend consulting the NCCN guidelines for Genetic/Familial High-Risk Assessment Breast and Ovarian.—Zachary Bessette