`
`Visretarerieee
`Lea
`=
`
`Seles
`
`Rockin’ For The Cure®
`
`
`Presented with support from i ;
`
`Hospira v. Genentech
`Hospira v. Genentech
`IPR2017-00805
`IPR2017-00805
`Genentech Exhibit 2085
`Genentech Exhibit 2085
`
`

`

`

`

`Version 1.2016
`
`NCCN Guidelines for Patients®
`
`heklatnienlt
`beerrere Aerhaag
`oan :
`Peano:
`
`Breast Cancer
`Early-Stage
`STAGES I AND II
`
`NCCN Foundation® gratefully acknowledges:
`
`SHARSHERET
`Sharsheret is proud to endorsethis important
`resource, the NCCN Guidelines for Patients:
`Breast Cancer. With this critical tool in hand,
`women nationwide have the knowledge they
`needto partnerwith their healthcare team to
`navigate the often complicated world of breast
`cancer care and make informed treatment
`decisions. www.sharsheret.org
`
`YOUNG SURVIVAL COALITION (YSC)
`Young Survival Coalition (YSC)is pleased to
`endorse the NCCN Guidelines for Patients:
`Breast Canceras an invaluable resource for
`young womendiagnosed with breast cancer and
`their co-survivors. This in-depth, illustrated series
`clearly explains what breast canceris, howit
`is treated and whatpatients can expect on the
`journey ahead. www.youngsurvival.org
`
`Special thank you to
`
`
`
`ROCKIN’ FOR THE
`CURE®
`NCCN Foundation wouldlike to
`thank Rockin‘ for the Cure for
`providing much needed support
`for the NCCN Guidelines for Patients! Rockin‘ For
`The Cure 2016 wasa giant success and we are
`incredibly grateful to the Rockin' For The Cure
`team for their hard work and passion to promote
`cancer awareness.Welook forward to 2017.
`www.rockinforthecure.net
`
`Support from
`
`NCCN AND NCCN FOUNDATION —
`BOARDSOF DIRECTORS
`Drs. Al B. Benson III and Alanah Fitch
`Joshua and Stephanie Bilenker
`Dr. and Mrs. Douglas W. Blayney
`Mara Bloom
`Rebecca Caires, MBA
`Peter F. Coccia, MD and Phyllis |. Warkentin, MD
`Gena Cook
`Dr. and Mrs. Thomas A. D'Amico
`Dr. and Mrs. Timothy J. Eberlein
`Paul F. Engstrom
`David S. Ettinger, MD, FACP, FCCP
`Theresa J. Franco, RN, MSN
`Brian Garofalo
`Jack A. Gentile, Jr.
`Matt Kalaycio, MD
`Mark F. Kochevar and Barbara Redmond
`Heather Kopecky
`Trisha Lollo
`Ray Lynch, CPA, MBA
`James and Marilyn Mohler
`Lisle M. Nabeil, MD
`Michael and Gwyneth Neuss
`Michael Parisi, MBA, MA
`Barbara Parker, MD
`Lori C Pickens, MHA
`Dorothy Puhy
`Denise K. Reinke, MS, NP
`Marc Samuels
`Gerrie Shields
`Dr. and Mrs. Samuel Silver
`Susan C. & Robert P. Stein
`The Honorable Elien O. Tauscher
`Jeff and Colleen Walker
`Robert C. Young, MD
`
`NCCN AND NCCN FOUNDATION —
`STAFF CONTRIBUTING $100
`OR MORE
`Anonymous
`Robert W. Carlson, MD and Stacey Starcher
`C. Lyn Fitzgerald, MJ
`Kristina Gregory
`Joseph Junod
`
`Lisa G. Kimbro, MBA, CPA
`Joan S. McClure
`Elizabeth Nardi
`Marcie Reeder, MPH
`Gary J. and Marianne Weyhmuller
`
`An additionalfifty-five (55) donations were
`received from other NCCNstaff members.
`
`Endorsed by
`
`BREAST CANCER ALLIANCE
`Receiving a cancer diagnosis can be
`overwhelming, both for the patient and their
`family. We support the NCCNguidelines for
`breast cancer with the knowledgethat these
`tools will help to equip patients with many of the
`educational resources, and answersto questions,
`they may seek. www.breastcanceralliance.org
`
`FORCE: FACING OUR RISK OF
`CANCER EMPOWERED
`As the nation’s leading organization serving the
`hereditary breast and ovarian cancer community,
`FORCE is pleased to endorse the NCCN
`Guidelines for Patients with breast cancer. This
`guide provides valuable, evidence-based, expert-
`reviewed information on the standardofcare,
`empowering patients to make informed decisions
`abouttheir treatment. www.facingourrisk.org
`
`LIVING BEYOND BREAST CANCER
`Receiving a diagnosis of breast canceris
`overwhelming. Having trusted informationis
`essential to help understand one’s particular
`diagnosis and treatment options. The information
`found in the NCCN Guidelines for Patients:
`Breast Canceris accessible, accurate, and will
`help every step of the way—from the momentof
`diagnosis through treatment. People can use the
`NCCNGuidelines for Patients: Breast Cancer to
`becomean informed partnerin their own care.
`www.|bbc.org
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES | AND 11), Version 1.2016
`
`

`

`
`
`NCCN aimsto improve the care given to patients with cancer. NCCN staff work with experts to create helpful programs and
`resources for many stakeholders. Stakeholders include health providers, patients, businesses, and others. One resourceis the
`series of booksfor patients called the NCCN Guidelines for Patients®. Each book presents the best practice for a type of cancer.
`The patient books are basedonclinical practice guidelines written for cancer doctors. These guidelines are called the NCCN
`Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Clinical practice guidelineslist the best health care options for
`groups of patients. Many doctors use them to help plan cancer treatmentfor their patients.
`
`Panels of experts create the NCCN Guidelines®. Mostof the experts are from NCCN Member Institutions. Panelists may include
`surgeons, radiation oncologists, medical oncologists, and patient advocates. Recommendations in the NCCN Guidelines are
`basedonclinical trials and the experience of the panelists. The NCCN Guidelines are updated at least once a year. When funded,
`the patient books are updatedto reflect the most recent version of the NCCN Guidelines for doctors. For more information about
`the NCCN Guidelines, visit NCCN.org/clinical.asp.
`
`NCCNstaff involved in developing the NCCN Guidelines for Patients include:
`
`Dorothy A. Shead, MS
`Director, Patient and Clinical Information
`Operations
`
`Lacey Marlow
`Associate Medical Writer
`Rachael Clarke
`
`Susan Kidney
`Graphic Design Specialist
`
`Laura J. Hanisch, PsyD
`Medical Writer/Patient Information
`Specialist
`
`Guidelines Data and Layout Coordinator
`
`Supported by NCCN Foundation®
`
`NATIONAL COMPREHENSIVE CANCER NETWORK
`
`F O U NDAT [© NcreePes
`
`@
`
`NCCN Foundation supports the mission of the National Comprehensive Cancer Network® (NCCN®) to
`improve the care of patients with cancer. Oneofits aims is to raise funds to create a library of booksfor
`patients. Learn more about the NCCN Foundation at NCCN.org/foundation.
`
`National Comprehensive Cancer Network (NCCN)
`275 Commerce Drive * Suite 300
`Fort Washington, PA 19034
`215.690.0300
`
`© 2016 National Comprehensive Cancer Network,Inc. All rights reserved.
`The NCCN Guidelines for Patients® andillustrations herein may not be reproduced in any form for any
`purpose without the express written permission of NCCN.
`
`
`
`NCCN Guidelines for Patients®
`Breast Cancer - Carcinomain Situ (STAGE 0), Version 1.2016
`
`

`

`essa NCGCN Guidelines
`
`Version 1.2016
`
`for Patients®
`
`Breast Cancer
`Early-Stage
`
`STAGES | AND Il
`
`Breast canceris the most commontypeof cancer in women. Learning that you
`have breast cancer can feel overwhelming. The goal of this book is to help you
`get the best care. It presents which cancertests and treatments for stages|
`and II breast cancer are recommended by experts.
`
`The National Comprehensive Cancer Network® (NCCN®)is a not-for-profit
`alliance of 27 of the world’s leading cancer centers. Experts from NCCN
`have written treatment guidelines for doctors who treat breast cancer. These
`treatment guidelines suggest whatthe best practice is for cancer care. The
`information in this patient book is based on the guidelines written for doctors.
`
`This book focuses on the treatmentof stages | & II breast cancer. Key points
`of the book are summarized in the related NCCN Quick Guide™. NCCN also
`offers patient resources on stages0, Ill, and IV breast cancer, ovarian cancer,
`sarcoma, lymphomas,and other cancertypes. Visit NCCN.org/patients for
`the full library of patient books, summaries, and other patient and caregiver
`resources.
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES | AND II), Version 1.2016
`
`{
`
`

`

`Breast Cancer- Early-Stage (STAGES| ANDII), Version 1.2016
`
`NCCNGuidelines for Patients®
`
`

`

`
`orece
`
`Breast Cancer
`Early-Stage
`
`STAGES | AND Il
`
`75 Part 7
`Follow-up care
`Presents key parts of long-term health
`care.
`
`81 Part8
`Breast cancer recurrence
`Presents your treatment optionsif the
`cancer returns.
`
`87 Part9
`Making treatment decisions
`Offers tips for choosing the best treatment.
`
`95 Glossary:
`96 Dictionary
`100 Acronyms
`
`103 NCCN Panel Members
`
`104 NCCN Member Institutions
`
`106 Index
`
`How to use this book
`
`Part 1
`Breast cancer basics
`Explains breast cancer andits treatment.
`
`15
`
`27
`
`39
`
`55
`
`65
`
`Part 2
`Treatment planning
`Describes how doctors plan your
`treatment.
`
`Part 3
`Breast cancer surgery
`Presents your options for removing the
`cancer and rebuilding breasts.
`
`Part 4
`Chemotherapy and HER2
`inhibitors
`Presents if these cancer drugs may be
`right for you.
`
`Part 5
`Radiation therapy
`Presents if you may needthis treatment
`and to which bodysites.
`
`Part 6
`Endocrine therapy
`Presents if you may need this treatment
`and whichtype.
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES I AND II), Version 1.2016
`
`

`

`
`
`Who should read this book?
`
`This bookis about treatment for stages | and
`ll breast cancer among women. Patients and
`those who support them—caregivers,family,
`and friends—mayfind this book helpful. It may
`help you discuss and decide with doctors what
`care is best.
`
`Where should | start
`reading?
`
`Starting with Part 1 may be helpful. It
`explains what stages| and II breast cancer
`is. Understanding the cancerwill help you
`understand its treatment. An overview of
`treatmentoptions is also given.
`
`Part 2 lists what health care is needed before
`treatment. Some types of health care help your
`doctors plan treatment. Other health care can
`address health issues beyond cancer treatment.
`
`Parts 3 through 7 are a step-by-step guide to
`your treatment options. Options are based on
`the best science that exists for stages | and
`ll breast cancer. Part 8 lists key parts to your
`health care once you are cancer-free. Part 9
`offers some helpful tips on getting the best care.
`
`Does the whole book apply
`to me?
`
`This bookincludes information for many
`situations. Your treatment team can help. They
`can point out what information applies to you.
`
`They can also give you moreinformation. As
`you read through this book, you mayfind it
`helpful to makea list of questions to ask your
`doctors.
`
`The recommendations in this book are based on
`
`science and the experience of NCCN experts.
`However, these recommendations may not be
`right for you. Your doctors may suggestother
`tests and treatments based on your health
`and otherfactors. If other recommendations
`are given, feel free to ask your treatment team
`questions.
`
`Making sense of medical
`terms
`
`In this book, many medical words are included.
`These are wordsthat you will likely hear from
`your treatment team. Most of these words may
`be newto you, andit may bea lot to learn.
`
`Don’t be discouraged as you read. Keep reading
`and review the information. Don’t be shy to ask
`your treatment team to explain a word or phrase
`that you do not understand.
`
`Words that you may not knoware defined in the
`text or in the Dictionary. Wordsin the Dictionary
`are underlined whenfirst used on a page.
`
`Acronymsare also defined whenfirst used
`and in the Glossary. Acronymsare short words
`formed from the first letters of several words.
`One example is DNA for deoxyribonucleic acid.
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES| AND II), Version 1.2016
`
`

`

`IOTeSedleid
`
`uidelinesforPatients® a
`
`

`

`
`
`Increases in female hormones amonggirls during
`puberty causetheir breasts to change. The stroma
`increases, the ducts grow and branch outlike tree
`
`limbs, and lobules form at the end of the ductslike
`leaves at the end of twigs. Lobules are small sacs
`that make breast milk after a baby is born. Breast milk
`drains from the millions of leaf-like lobules into the
`
`ducts that connectto the nipple. See Figure 1.1 for a
`look inside women’s breasts.
`
`Lymph is a clearfluid that gives cells water and food
`and helpsto fight germs. It drains from breast tissue
`into lymph vessels within the stroma. See Figure 1.2.
`Then, it travels to the breast’s lymph nodes, most
`of which are in your armpit. Lymph nodesare small
`structures thatfilter and remove germs from lymph.
`Nodes near the armpit are called axillary lymph
`nodes.
`
`
`
`You've learned that you have breast
`cancer. It's common to feel shocked
`
`and confused. Part 1 reviews some
`
`basics that may help you learn about
`breast cancer and its treatment.
`
`
`
`Women’s breasts
`
`Before learning about breast cancer,it is helpful to
`know aboutbreasts. The ring of darker skin seen on
`the outside of the breast is called the areola. The
`raised tip in the middle of the areola is called the
`
`nipple. In young girls, there are small ducts under the
`nipple that branchinto fatty tissue like early growth
`from a seedling. These immature ducts are supported
`by connective tissue called stroma.
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES | AND II), Version 1.2016
`
`

`

`Oltaes itesiaite
`
`Women's breasts
`
`
`Figure1.1
`
`fe
`ie
`
`insideswomen’s breasts stroma
`—hipple
`
`
`
`Insideofwomen’sbreastsCUES
`millionsoflobulesthattformbreast ie Wed
`
`milk after a babyiis born. Breastmilk14b) i" Eo
`
`
`
`duct
`drains fromtheJobulesinto ducts
`:
`
`that carry the milkto the nipple.
`Around the|lobules Bnd ductsis soft
`tissue called stroma.
`
`
`
`
`
`i_ Figure 1.2
`~ Breast lymph vessels
`atabodes
`
`
`Lymiisaeerfluid uegives cells
`water and food and helps to fight
`germs. It drains from breasttissue
`into lymph1vessels within the stroma.
`it then travels to the breast’s lymph
`nodes, mostof whicharein the
`armpit (“axilla”).
`
`
`
`ase
`
`aa
`
`Sete
`
`
`
`x
`
`UWlustration eoyrighht© 2016 veg Medical Media,All rights reserver ew .Nucleusinc.com
`=.
`,
`
`
`
`es
`i
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES | AND II), Version 1.2016
`
`7
`
`

`

`Breast cancer
`
`Breast cancer
`
`Cancer is a disease of cells. Carcinomas are cancers
`of cells that make up the skin and the tissue that
`lines or covers organs. Almostall breast cancers are
`carcinomas. In the breast, carcinomasstart in the
`
`cells lining either the ducts or lobules, but most breast
`cancersstart in ductal cells.
`
`Inside of cells are codedinstructions for building
`new cells and controlling how cells behave. These
`instructions are called genes. Genesare a part
`of DNA (deoxyribonucleic acid), which is grouped
`together into bundles called chromosomes. See
`Figure 1.3. Abnormal changes (mutations) in
`genes cause normal cells to become cancercells.
`Researchersarestill trying to learn what causes
`genes to mutate and cause cancer.
`
`Cancer cells don’t behavelike normal cells in three
`key ways. First, mutations in genes cause normal
`cells to grow more quickly andlive longer. Normal
`cells grow and then divide to form newcells when
`needed. They also die when old or damaged as
`shownin Figure 1.4. In contrast, cancer cells make
`newcells that aren’t needed and don’t die quickly
`whenold or damaged. Overtime, breast cancer cells
`form a masscalled the primary tumor.
`
`The second waycancercells differ from normal
`cells is that they can grow into surrounding tissues.
`If not treated, the primary tumor can extend beyond
`
`the walls of lobules or ducts into the stroma. Breast
`cancers that haven't growninto the stroma are called
`“noninvasive breast cancer.” Breast cancers that have
`growninto the stroma, such as stages | andIl, are
`called “invasive breast cancer.”
`
`Third, unlike normal cells, cancer cells can leave the
`breast and form tumorsin other parts of the body.
`This processis called metastasis. In this process,
`cancercells break away from the tumor and merge
`with blood or lymph. Then, the cancercells travel
`in blood or lymph through vessels to othersites.
`Thefirst site is your axillary lymph nodes. Common
`distant sites include your bones, lungs, brain, and
`liver. Once cancercells are in othersites, they can
`form secondary tumors and may cause major health
`problems.
`
`
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES I AND II), Version 1.2016
`
`

`

`| Breastcancer
`Teereast [uettal sytt
`
`Figure 1.3
`Genetic materialin cells
`
`Most human cells contain the
`
`“blueprint of life’—the plan by
`which our bodies are made and
`
`work. The plan is found inside of
`chromosomes,whichare long
`strands of DNA thataretightly
`wrapped around proteins. Genes
`are small pieces of DNA that
`contain instructions for building
`new cells and controlling how cells
`behave. Humans have about 24,000
`genes.
`
`humancell
`
`chromosomes
`
`DNA
`
`
`
`Itustration Copyright © 2016 Nucleus Medical Media, All rights reserved. www.nucleusinc.com
`
`Figure 1.4
`Normalcell growth vs.
`Cancercell growth
`Normalcell growth
`cancercell growth
`Ry®
`Normal cells increase in number
`*.
`7%
`
`when they are needed and die
`whenold or damaged. In contrast,
`
`cancercells quickly make new
`cells and live longer because of
`abnormal changesin genes.
`
` 4
`
`heaity
`cell
`
`wa i
`7s
`_
`f
`Eee ea) c a th
`
`ell
`
`dea
`
`Ayra?
`
`
`t
`No cell death
`
`t
`
`Many more
`new cells
`
`INustration Copyright © 2016 Nucleus Medical Media, All rights reserved. www.nucleusinc.com
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES| AND II), Version 1.2016
`
`9
`
`

`

`ge| Treatment options
`
`Cancer stage
`
`Treatment options
`
`You will be making many choices about your
`treatmentfor breast cancer. One choice may be
`whetherto join a clinical trial. Clinical trials assess
`howsafe and helpful tests and treatments are. When
`found to be safe and helpful, tests and treatments
`from a clinical trial may become tomorrow’s standard
`of care. Clinical trials are the treatment option that is
`preferred by NCCN experts. Ask your treatment team
`if there is an openclinical trial that you can join. You
`can alsofind clinical trials through the websites listed
`in Part 9.
`
`If you will not be joining a trial, other options are
`briefly described next. As shown in Figure 1.5,
`treatmentfor stage | or Il breast cancer has many
`parts. First, the cancer and your health will need to be
`assessed as discussed in Part 2 Treatment planning.
`Your treatmentoptions will be based ontest results.
`
`This book focuses on cancertreatment, but
`supportive care is also important. Supportive care
`doesn't aim to treat cancer but aims to improve
`quality oflife. It can address many needs. One
`example is treatment for physical and emotional
`symptoms. Supportive care can also help with
`treatment decisions as you may have more than
`one option. It can also help with coordination of care
`between health providers. Talk with your treatment
`team to plan the best supportive care for you.
`
`
`
`
`
`A cancerstageis a rating by your doctors of the
`extent of the cancer.It is used to plan which tests may
`be needed and which treatments are best for you. The
`AJCC (American Joint Committee on Cancer) staging
`system is used to stage breast cancer.
`
`Rating of the cancer stageis often done twice. The
`first rating is based on tests before treatment andis
`called the clinical stage. Exactly how far the cancer
`has spread and how manyaxillary lymph nodes have
`cancer can’t be knownuntil after surgery. Thus, your
`doctors will rate the cancer again after surgery. This
`rating is called the pathologic stage.
`
`Breast cancer has 5 stages ranging from 0 to IV. The
`focus of this book is on stages| andIl. These breast
`
`cancers have growninto the stroma but not into the
`breast skin or chest wall. The cancer hasn’t spread to
`distant sites. Clinical stages | and II are defined as:
`
`Stage |
`* Breast tumors are 2 cm (centimeters) or
`smaller in size and appear not to have spread
`to any lymph nodes.
`
`Stage IIA
`* Breast tumors are no larger than 2 cm or no
`breast tumor has been found. The cancer
`appears to have spread to a few axillary
`lymph nodes.
`* Breast tumors are larger than 2 cm but no
`larger than 5 cm. There are no signs of cancer
`in any lymph nodes.
`
`Stage IIB
`« Breast tumors are larger than 2 cm but no
`larger than 5 cm. The cancerappears to have
`spread to a few axillary lymph nodes.
`* Breast tumors are larger than 5 cm with no
`signs of cancer in any lymph nodes.
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES | AND I), Version 1.2016
`
`

`

`Rl
`
`stestigreatestmsl
`
`Treatment options
`
`Figure 1.5 Common treatment path
`
`Treatment for stages | and II breast cancer has many parts. As such, you will have many
`choicesto face. Read Parts 2 through 8 to learn what your options are.
`
`& ._&
`ab
`
`bad
`
`Chemotherapy and
`HER?inhibitors
`
`PARTa
`
`i.Ca
`
`1
`|
`
`Clinicaltrials
`
`=
`
`1
`ri
`
`Treatment planning
`
`cs
`
`ad a
`
`ae
`We
`
`Total mastectomy
`Lymph node surge
`Breast reconstruction
`
`;
`
`i
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES | AND Il), Version 1.2016
`
`11
`
`

`

`Breast cancer surgery
`Breast reconstruction
`
`is a surgery that inserts breast
`implants
`Surgery to remove the cancer is a central part of
`
`
`
`or uses your body tissue to make a more
`
`
`treatment for stages I and 11 breast cancer. Cancer
`
`
`normal-looking breast mound. Following the cancer
`
`surgery, or in some cases at the same time, you may
`in the breast and any lymph nodes will be removed.
`
`
`want to have breast reconstruction. However, some
`
`
`
`However, other treatments will likely be used with
`
`
`women use external fake breasts or do nothing.
`
`surgery to treat the cancer.
`
`
`
`Breast reconstruction is described in more detail in
`Treatment for stages I and II breast cancer has many
`
`Part 3 Breast cancer surgery.
`
`
`parts. As such, you will have many choices to face.
`Chemotherapy and HER2 inhibitors
`
`
`Read Parts 2 through 8 to learn what your options are.
`
`
`You may receive chemotherapy and HER2 (human
`Lumpectomy
`and a total mastectomy are two types of
`
`
`
`
`
`epidermal growth factor receptor 2) inhibitors after
`
`surgery. These cancer drugs lower the chances of
`
`
`breast surgery used for stages I and II breast cancer.
`
`
`
`breast cancer returning. Treatment for this purpose is
`
`
`A lumpectomy is a surgery that removes the tumor
`
`along with normal-looking tissue around its edge.
`
`
`
`
`called adjuvant treatment. Chemotherapy, or "chemo,"
`
`
`includes drugs that disrupt the life cycle of cancer
`
`
`
`
`The normal-looking tissue is called a surgical margin.
`
`
`
`Lumpectomy is a breast-conserving surgery because
`
`
`cells. Thus, no new cells are made to replace dying
`
`
`
`
`cells. HER2 inhibitors stop certain signals that tell
`
`
`most of the normal breast tissue won't be removed. A
`
`
`
`total mastectomy is a surgery that removes the entire
`
`cancer cells to grow. Part 4 Chemotherapy and HER2
`
`
`addresses if these treatments are an option
`
`breast but not any chest muscle.
`inhibitors
`
`Part 3 Breast cancer
`
`
`
`you. is an option for surgery presents which surgery
`for you.
`
`�
`
`Radiation therapy
`
`Surgery is often the first treatment for stages I &.
`
`
`
`Radiation therapy
`
`
`
`11 breast cancer. It may not be the first treatment
`uses high-energy rays to treat
`
`
`if you have a large breast tumor and want to have
`
`
`cancer. The rays damage the genes in cells. This
`
`
`a lumpectomy. In this case, you may first receive
`
`either kills the cancer cells or stops new cancer cells
`
`cancer drugs to try to shrink the tumor. Use of cancer
`
`from being made. If you will receive chemotherapy,
`
`
`
`drugs for this purpose is called neoadjuvant (or
`
`
`radiation therapy is most often given afterward.
`
`preoperative) treatment.
`
`
`
`
`Otherwise, radiation therapy follows surgery.
`Part 5
`
`
`
`addresses if radiation therapy is an
`
`Radiation therapy
`At the time of the breast surgery, most women with
`
`
`
`option for you.
`stage I or II breast cancer will have some axillary
`Endocrine therapy
`
`
`lymph nodes removed. Lymph nodes will be removed
`
`
`by one or two methods. A sentinel lymph node biopsy
`Female hormones help some breast cancers grow.
`
`
`
`Endocrine therapy
`
`
`is a surgery that finds and removes the first lymph
`
`
`includes treatments that stop
`
`cancer growth caused by hormones. Endocrine
`
`nodes to which breast cancer spreads. It is also
`
`
`
`called a sentinel lymph node dissection. An axillary
`
`
`
`
`therapy is sometimes called hormone therapy but is
`
`removes more axillary lymph
`lymph node dissection
`
`
`not the same as hormone replacement therapy. It is
`
`
`used as an adjuvant treatment and may be started
`
`nodes than a sentinel lymph node biopsy. Part 3
`
`
`
`
`is an which surgery Breast cancer surgery addresses
`
`
`during or after radiation therapy.
`
`option for you.
`
`NCCN Guidelines for Patients
`
`
`
`
`
`
`Breast Cancer -Early-Stage (STAGES I AND 11), Version 1.2016
`
`®
`
`12
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`

`

`T here are 4 types of endocrine therapy. Antiestrogens
`
`
`
`Breast cancer recurrence
`Testing to assess the outcomes of cancer treatment is
`
`
`
`
`are drugs that stop the effect of estrogen on cancer
`
`
`
`part of follow-up care. Follow-up care is addressed in
`
`
`
`cell growth. Aromatase inhibitors are drugs that
`
`Part 7. Testing may show that the cancer has returned
`
`
`
`lower estrogen levels in the body. Ovarian ablation
`(recurrence).
`
`
`
`
`uses either surgery or radiation therapy to stop
`Part 8 Breast cancer recurrence
`
`
`
`addresses what types of treatment are options for you
`
`
`
`ovaries from making estrogen. Ovarian suppression
`if the cancer returns.
`
`is the use of drugs to stop the ovaries from making
`
`
`
`
`estrogen. Part 6 Endocrine therapy addresses if and
`
`
`
`what types of endocrine therapy are options for you.
`
`NCCN Guidelines for Patients
`
`
`
`
`
`
`Breast Cancer -Early-Stage (STAGES I AND 11), Version 1.2016
`
`®
`
`13
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`

`
`
`
` SaeNalsa
`
`Review
`
`*
`
`Inside of women’s breasts are lobules, ducts,
`and stroma. Lobules are structures that make
`breast milk. Ducts carry breast milk from the
`lobules to the nipple. Stromais a soft tissue
`that surrounds the lobules and ducts.
`
`* Breast cancer often starts in the lobules or
`ducts and then growsinto the stroma.
`
`* Breast cancer can spread outside the breast
`to vital organs through lymph orblood.
`
`* Breast cancer that is stage | or Ii has grown
`into the stroma but not into the breast skin or
`chest wall. It has not spread to distant sites.
`
`Clinical trials are the treatment option thatis
`preferred by NCCN experts. Other options
`involve surgery, chemotherapy, HER2
`inhibitors, radiation therapy, endocrine
`therapy, follow-up care, and recurrence
`treatment. Parts 2 through 8 present what
`your options maybe.
`
`
`
`
`
`
`
`
`
`
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES 1 AND II), Version 1.2016
`
`14
`
`

`

`
`
`

`

`
`
`Seemcc
`Dyeceeactlestenitis
`aaaieee
`
`
`
`Doctors plan treatment with many
`sourcesof information. These sources
`
`include tests of your health and the
`cancer. Part 2 describes who should
`
`receive which tests before treatment.
`
`Some of these tests are repeated
`after treatment. Besides tests, Part 2
`describes other types of care that are
`important to receive before cancer
`treatment.
`
`Medical history
`
`Your medical history includes any health events and
`medicines you've taken in your life. Your doctorwill
`want to know aboutillnesses, breast biopsies, prior
`treatment with radiation, and if you are pregnant.It
`may help to makea list of old and new medications
`while at home to bring to your doctor’soffice.
`
`Breast cancer and other health conditions can run in
`
`families. Thus, your doctorwill ask about the medical
`history of your relatives. About 1 out of 10 breast
`cancers are due to abnormal genes that are passed
`downfrom a parentto a child. Such cancers are
`called hereditary breast cancer.
`
`A medical history is one of the tests needed for
`treatment planning. See Chart 2.1 for a completelist
`of care that is recommendedprior to treatment. Some
`types of care are for anyone with stage I orIl breast
`cancer while others may be useful for some women.
`
`NCCN Guidelines for Patients®
`Breast Cancer- Early-Stage (STAGES | AND 11), Version 1.2016
`
`16
`
`

`

` AernCaa eu)
`
`Physical exam
`
`Blood tests
`
`Doctors often perform a physical exam along with
`taking a medical history. A physical exam is a study of
`your bodyfor signs of disease. During this exam, your
`doctorwill listen to your lungs, heart, and gut.
`
`Your doctorwill also look at and feel parts of your
`body. This is done to see if organs are of normal
`size, are soft or hard, or cause pain when touched.
`A clinical breast exam involves your doctor touching
`your breasts and nearby lymph nodes. Your breasts
`may befelt while you sit or stand up as well as when
`you lie back. Some womenfeel uneasy having their
`breasts touchedbytheir doctor. Keep in mindthatthis
`test provides important information andis quick.
`
`Blood tests may be done to check for any health
`problemsbefore starting treatment. For a bloodtest,
`a needle will be inserted into your vein to remove a
`sample of blood. The needle maybruise your skin
`and you mayfeel dizzy from the blood draw. Your
`blood sample will then be sent to a lab where a
`pathologist will testit.
`
`Complete blood count
`A CBC (complete blood count) measures the number
`of blood cells in a blood sample. It includes numbers
`of white blood cells, red blood cells, and platelets.
`Cancer and other health problems can cause low or
`high counts.
`
`Chart 2.1 Health care before cancer treatment
`
`i
`| ee Maintestsand: services— Heche’
`
`le eS mr
`
`_Other care basedonsignsand symptoms
`
`* Medical history
`
`* Physical exam
`
`* Complete blood count
`
`* Liver function tests
`
`Diagnostic bilateral mammogram
`
`* Bone scan
`
`Ultrasound if needed
`
`¢ Chest diagnostic CT
`
`Breast MRIis an option
`
`¢ Abdominal + pelvic diagnostic CT or MRI
`
`¢ Lymph node biopsy
`
`Pathology review
`
`Hormone receptortest
`
`HER2 test
`
`Genetic counseling if hereditary breast
`canceris likely
`
`Fertility counseling if you can have babies
`
`* Distress screening
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES | AND Il), Version 1.2016
`
`17
`
`

`

` Imagingtests
`
`Liver function tests
`Your liver is an organ in the upperright side of your
`abdomen. It does many important jobs, such as
`remove toxins from your blood. Liver function tests
`assess for chemicals that are made or processed by
`the liver. Levels that are too high or low maysignal
`that the cancer has spread to distant sites. One such
`chemical is ALP (alkaline phosphatase). High levels
`of ALP may mean that the cancer has spread to your
`liver or bones.
`
`Imaging tests
`
`Imaging tests make pictures (images) of the insides
`of your body. They can show which sites have cancer.
`This information helps your doctors stage the cancer.
`
`Your treatment team will tell you how to prepare
`for these tests. You may need to stop taking some
`medicines and stop eating and drinking for a few
`hours before the scan. Tell your doctors if you get
`nervous whenin small spaces. You may be given a
`sedative to help you relax.
`
`Bilateral diagnostic mammogram
`A mammogram is a picture of the insides of your
`breast. The pictures are madeusing x-rays.
`Mammogramsthat are used for breast cancer
`screening are often made from two x-rays of each
`breast. A computer combines the x-rays to make
`detailed pictures. See Figure 2.1 for more information.
`
`Many womendiagnosed with breast cancer have
`already had a bilateral diagnostic mammogram. If
`you haven't hadthis test, it is advised. A bilateral
`mammogram is a picture of each breast. Diagnostic
`mammograms are made with more x-rays from
`different angles than screening mammograms. By
`using more x-rays, the picture is clearer and can
`better show the size and number of tumors.
`
`NCCN Guidelines for Patients®
`Breast Cancer - Early-Stage (STAGES | AND II), Version 1.2016
`
`Ultrasound
`
`Ultrasound is a test that uses sound waves to make
`pictures. Forthis test, you will need to lie down on
`a table. Next, a technician or doctor will hold the
`ultrasound probe on top of your breast. The probe
`may also be placed below your armpit to view your
`lymph nodes.
`
`Breast MRI
`If the mammographyand ultrasound images are
`unclear, your doctors may want youto get a breast
`MRI (magnetic resonance imaging). This test uses
`a magnetic field and radio waves to makepictures
`of the insides of your breasts. Before the test, a
`
`contrast dye maybeinjected into your vein to make
`the pictures clearer. The dye may cause youto feel
`flushed or get hives. Rarely, serious allergic reactions
`occur. Tell your doctor if you have had bad reactions
`before.
`
`For breast MRI, you must remove your top and bra
`andlie face down on a table. The table has padded
`openingsfor your breasts. In the openings, there are
`coils that help to make pictures. During breast MRI,
`the table moves slowly through the tunnelof the MRI
`machine.
`
`Bone scan
`A bone scan is recommendedif you have bone pain
`or if ALP levels are high. Before the pictures are
`taken, a radiotracerwil! be injected into your vein.
`The most common radiotracer used for bone scans
`
`is technetium. You will need to wait about 3 hours for
`the radiotracer to enter your bones. A special camera
`is used to take pictures while youlie still on a table.
`It takes 45 to 60 minutes to complete the pictures.
`Areas of b