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Inflammatory Breast Cancer Gets Its Own Set of NCCN Guidelines


 

HOLLYWOOD, FLA. — Inflammatory breast cancer, which used to be covered under the National Comprehensive Cancer Network's recommendations for locally advanced breast cancer, now has separate guidelines of its own.

“Inflammatory breast cancer is a distinct pathologic entity, and it's about time we formally recognized this,” Dr. Robert W. Carlson said, announcing the new category at the annual conference of the National Comprehensive Cancer Network.

Advocates have long criticized the inclusion of this very aggressive form of breast cancer in a general breast cancer treatment algorithm. “Giving it its own set of guidelines was the right thing to do. We should have done it with or without advocacy criticism,” said Dr. Carlson, professor of medicine at Stanford (California) University and chair of the NCCN breast cancer guidelines committee.

The classic criteria defining inflammatory breast cancer are dermal edema of a third or more of the breast, erythema of a third or more of the breast, and a palpable border to the erythema. These findings are usually, but not always, associated with dermal lymphatic involvement of the tumor, he said.

Historically, inflammatory breast cancer has carried a very unfavorable prognosis, Dr. Carlson said. He added that any cellulitis of the breast that occurs in a nongravid, nonlactating woman should be assumed to be inflammatory breast cancer until a biopsy proves differently.

The new guidelines say initial staging should include a determination of estrogen-receptor (ER), progesterone-receptor (PR), and human epidermal growth factor-receptor 2 (HER2) status; a bilateral diagnostic mammogram; and ultrasound, bone scan, and computed tomography (CT) scan of the chest, abdomen, and pelvis. Once staging is completed, the guidelines suggest treatment with preoperative anthracycline-based chemotherapy with or without a taxane.

HER2 is frequently overexpressed or positive in inflammatory breast cancers. In such cases, trastuzumab (Herceptin) or a trastuzumab-containing regimen should be used, Dr. Carlson said.

If the woman responds to neoadjuvant chemotherapy (“as the vast majority do” said Dr. Carlson), the new guidelines call for a total mastectomy with level one and two axillary dissection plus radiation to the chest wall and supraclavicular regions. Delayed breast reconstruction may also be considered at this time.

After surgery and radiation, the guidelines suggest that chemotherapy be resumed, if it was not completed preoperatively. They also call for endocrine treatment for ER-positive disease. If the tumor is HER2 positive, the guidelines recommend 1 year of trastuzumab.

Dr. Carlson disclosed that he is a consultant to AstraZeneca Pharmaceuticals LP, Genomic Health, and Pfizer Inc., and that he receives grant and research support from AstraZeneca and Genentech Inc.

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