The NCCN recently updated its BC clinical practice guidelines. These guidelines and their accompanying algorithms are widely used in the management of the oncology patient.

Among the areas discussed in the recent guidelines are the evaluation and primary treatment of ductal carcinoma in situ (DCIS); the management of DCIS after primary treatment; the workup of nonmetastatic (M0) invasive BC; and the overall locoregional treatment of cT1-3, cN0 or cN+, M0 disease. The guidelines also provide recommendations for surgical axillary staging, radiation therapy, and adjuvant and regional nodal radiation therapy after breast-conserving surgery (BCS). Additionally, they address genetic counseling and recommend assessing for psychological distress, fertility, and sexual health. There are various therapeutic interventions available to preserve both ovarian function and future fertility.

NCCN categories rate the quality of the available evidence and include:

• Category 1, which indicates that there is a high-level of evidence available, there is uniform consensus for the recommendation, and the intervention is appropriate.
• Categories 2A and 2B indicate that a lower level of evidence is available compared with category 1; however, consensus is present, and the intervention is appropriate.
• Category 3 indicates that the recommendation is based on any level of evidence, there is major disagreement among NCCN raters, but the intervention is still considered appropriate.

The recommendations for the management of DCIS include the use of BCS with whole-beam breast radiation therapy with or without boost radiation (i.e., an extra radiation dose given after the regular sessions of radiation are completed to reduce the chances of disease recurrence) (category 1); total mastectomy with or without sentinel lymph node biopsy with optional reconstructive surgery (category 2A); BCS plus accelerated partial breast irradiation in which localized radiation is utilized following BCS in selected "low risk" or "suitable" patients (e.g., those with a small tumor, clear margins, and negative nodes) (category 2A); and BCS alone (category 2B).

After primary treatment for DCIS with breast-conserving therapy (BCT, i.e., BCS typically followed by radiation), the guidelines recommend the use of endocrine therapy (ET) with tamoxifen for pre- and postmenopausal women or an aromatase inhibitor (AI) for postmenopausal woman with estrogen receptor–positive disease to reduce the risk of ipsilateral BC recurrence.

An AI is suggested for those aged younger than 60 years or for those who are concerned about tamoxifen's potential risk of thromboembolism. This is a category 1 recommendation for those undergoing BCT followed by radiation therapy. If hormone therapy is started following surgery only, the recommendation is a category 2A. Patients on this regimen should be followed up every 6 to 12 months for 5 years and then yearly. They should also receive a yearly diagnostic mammogram.

In women with cT1-3, cN0 or cN+, M0 disease, if systemic chemotherapy and radiation therapy are indicated after surgery, radiation is usually delivered following the completion of chemotherapy. However, if the chemotherapy regimen consists of cyclophosphamide/methotrexate/fluorouracil, radiation therapy may be administered concurrently. There appears to be no difference in outcome for sequential or concurrent ET when ET is administered while receiving radiation although the guidelines caution that it may be preferable to initiate ET following radiation therapy to reduce the occurrence of possible adverse effects.

Pharmacists should be aware of these latest recommendations in order to optimize the care of their patients with BC.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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