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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Locoregional therapy of locally advanced breast cancer: a clinical practice guideline</title>
<author><name sortKey="Brackstone, M" sort="Brackstone, M" uniqKey="Brackstone M" first="M." last="Brackstone">M. Brackstone</name>
<affiliation><nlm:aff id="af1-conc-22-s54">Surgical Oncology, London Regional Cancer Program, London Health Sciences Centre; and Departments of Surgery and Oncology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Fletcher, G G" sort="Fletcher, G G" uniqKey="Fletcher G" first="G. G." last="Fletcher">G. G. Fletcher</name>
<affiliation><nlm:aff id="af2-conc-22-s54">Program in Evidence-Based Care, Cancer Care Ontario; and Department of Oncology, McMaster University, Hamilton, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Dayes, I S" sort="Dayes, I S" uniqKey="Dayes I" first="I. S." last="Dayes">I. S. Dayes</name>
<affiliation><nlm:aff id="af3-conc-22-s54">Juravinski Cancer Centre, Hamilton Health Sciences; and Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Madarnas, Y" sort="Madarnas, Y" uniqKey="Madarnas Y" first="Y." last="Madarnas">Y. Madarnas</name>
<affiliation><nlm:aff id="af4-conc-22-s54">Department of Oncology, Queen’s University, Kingston, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sengupta, S K" sort="Sengupta, S K" uniqKey="Sengupta S" first="S. K." last="Sengupta">S. K. Sengupta</name>
<affiliation><nlm:aff id="af5-conc-22-s54">Cancer Centre of Southeastern Ontario, Kingston General Hospital; and Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Verma, S" sort="Verma, S" uniqKey="Verma S" first="S." last="Verma">S. Verma</name>
<affiliation><nlm:aff id="af6-conc-22-s54">The Ottawa Hospital Cancer Centre; and Department of Medicine, Division of Medical Oncology, University of Ottawa, Ottawa, ON.</nlm:aff>
</affiliation>
</author>
</titleStmt>
<publicationStmt><idno type="wicri:source">PMC</idno>
<idno type="pmid">25848339</idno>
<idno type="pmc">4381791</idno>
<idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381791</idno>
<idno type="RBID">PMC:4381791</idno>
<idno type="doi">10.3747/co.22.2316</idno>
<date when="2015">2015</date>
<idno type="wicri:Area/Pmc/Corpus">002D71</idno>
<idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002D71</idno>
</publicationStmt>
<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Locoregional therapy of locally advanced breast cancer: a clinical practice guideline</title>
<author><name sortKey="Brackstone, M" sort="Brackstone, M" uniqKey="Brackstone M" first="M." last="Brackstone">M. Brackstone</name>
<affiliation><nlm:aff id="af1-conc-22-s54">Surgical Oncology, London Regional Cancer Program, London Health Sciences Centre; and Departments of Surgery and Oncology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Fletcher, G G" sort="Fletcher, G G" uniqKey="Fletcher G" first="G. G." last="Fletcher">G. G. Fletcher</name>
<affiliation><nlm:aff id="af2-conc-22-s54">Program in Evidence-Based Care, Cancer Care Ontario; and Department of Oncology, McMaster University, Hamilton, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Dayes, I S" sort="Dayes, I S" uniqKey="Dayes I" first="I. S." last="Dayes">I. S. Dayes</name>
<affiliation><nlm:aff id="af3-conc-22-s54">Juravinski Cancer Centre, Hamilton Health Sciences; and Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Madarnas, Y" sort="Madarnas, Y" uniqKey="Madarnas Y" first="Y." last="Madarnas">Y. Madarnas</name>
<affiliation><nlm:aff id="af4-conc-22-s54">Department of Oncology, Queen’s University, Kingston, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sengupta, S K" sort="Sengupta, S K" uniqKey="Sengupta S" first="S. K." last="Sengupta">S. K. Sengupta</name>
<affiliation><nlm:aff id="af5-conc-22-s54">Cancer Centre of Southeastern Ontario, Kingston General Hospital; and Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON.</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Verma, S" sort="Verma, S" uniqKey="Verma S" first="S." last="Verma">S. Verma</name>
<affiliation><nlm:aff id="af6-conc-22-s54">The Ottawa Hospital Cancer Centre; and Department of Medicine, Division of Medical Oncology, University of Ottawa, Ottawa, ON.</nlm:aff>
</affiliation>
</author>
</analytic>
<series><title level="j">Current Oncology</title>
<idno type="ISSN">1198-0052</idno>
<idno type="eISSN">1718-7729</idno>
<imprint><date when="2015">2015</date>
</imprint>
</series>
</biblStruct>
</sourceDesc>
</fileDesc>
<profileDesc><textClass></textClass>
</profileDesc>
</teiHeader>
<front><div type="abstract" xml:lang="en"><sec><title>Questions</title>
<list list-type="order"><list-item><p>In female patients with locally advanced breast cancer (<sc>labc</sc>
) and good response to neoadjuvant chemotherapy (<sc>nact</sc>
), including endocrine therapy, what is the role of breast-conserving surgery (<sc>bcs</sc>
) compared with mastectomy?</p>
</list-item>
<list-item><p>In female patients with <sc>labc</sc>
,
<list list-type="alpha-lower"><list-item><p>is radiotherapy (<sc>rt</sc>
) indicated for those who have undergone mastectomy?</p>
</list-item>
<list-item><p>does locoregional <sc>rt</sc>
, compared with breast or chest wall <sc>rt</sc>
alone, result in a higher survival rate and lower recurrence rates?</p>
</list-item>
<list-item><p>is <sc>rt</sc>
indicated for those achieving a pathologic complete response (p<sc>cr</sc>
) to <sc>nact</sc>
?</p>
</list-item>
</list>
</p>
</list-item>
<list-item><p>In female patients with <sc>labc</sc>
who receive <sc>nact</sc>
, is the most appropriate axillary staging procedure sentinel lymph node biopsy (<sc>slnb</sc>
) or axillary dissection? Is <sc>slnb</sc>
indicated before <sc>nact</sc>
rather than at the time of surgery?</p>
</list-item>
<list-item><p>How should female patients with <sc>labc</sc>
that does not respond to initial <sc>nact</sc>
be treated?</p>
</list-item>
</list>
</sec>
<sec><title>Methods</title>
<p>This guideline was developed by Cancer Care Ontario’s Program in Evidence-Based Care (<sc>pebc</sc>
) and the Breast Cancer Disease Site Group (<sc>dsg</sc>
). A systematic review was prepared based on literature searches conducted using the <sc>medline</sc>
and <sc>embase</sc>
databases for the period 1996 to December 11, 2013. Guidelines were located from that search and from the Web sites of major guideline organizations. The working group drafted recommendations based on the systemic review. The systematic review and recommendations were then circulated to the Breast Cancer <sc>dsg</sc>
and the <sc>pebc</sc>
Report Approval Panel for internal review; the revised document underwent external review. The full three-part evidence series can be found on the Cancer Care Ontario Web site.</p>
</sec>
<sec><title>Recommendations</title>
<list list-type="bullet"><list-item><p>For most patients with <sc>labc</sc>
, modified radical mastectomy should be considered the standard of care. For some patients with noninflammatory <sc>labc</sc>
, <sc>bcs</sc>
can be considered on a case-by-case basis when the surgeon deems that the disease can be fully resected and the patient expresses a strong preference for breast preservation.</p>
</list-item>
<list-item><p>For patients with <sc>labc</sc>
, <sc>rt</sc>
after mastectomy is recommended.</p>
</list-item>
<list-item><p>It is recommended that, after <sc>bcs</sc>
or mastectomy, patients with <sc>labc</sc>
receive locoregional <sc>rt</sc>
encompassing the breast or chest wall and local node-bearing areas.</p>
</list-item>
<list-item><p>It is recommended that postoperative <sc>rt</sc>
remain the standard of care for patients with <sc>labc</sc>
who achieve p<sc>cr</sc>
to <sc>nact</sc>
.</p>
</list-item>
<list-item><p>It is recommended that axillary dissection remain the standard of care for axillary staging in <sc>labc</sc>
, with the judicious use of <sc>slnb</sc>
in patients who are advised of the limitations of the current data.</p>
</list-item>
<list-item><p>Although <sc>slnb</sc>
either before or after <sc>nact</sc>
is technically feasible, the data are insufficient to make any recommendation about the optimal timing of <sc>slnb</sc>
with respect to <sc>nact</sc>
. Limited data suggest higher sentinel lymph node identification rates and lower false negative identification rates when <sc>slnb</sc>
is conducted before <sc>nact</sc>
; however, those data must be balanced against the requirement for two operations if <sc>slnb</sc>
is not performed at the time of resection of the main tumour.</p>
</list-item>
<list-item><p>It is recommended that patients receiving neoadjuvant anthracycline–taxane-based therapy (or other sequential regimens) whose tumours do not respond to the initial agent or agents, or who experience disease progression, be expedited to the next agent or agents of the regimen.</p>
</list-item>
<list-item><p>For patients who, in the opinion of the treating physician, fail to respond or progress on first-line <sc>nact</sc>
, several therapeutic options can be considered, including second-line chemotherapy, hormonal therapy (if appropriate), <sc>rt</sc>
, or immediate surgery (if technically feasible). Treatment should be individualized through discussion at a multidisciplinary case conference, considering tumour characteristics, patient factors and preferences, and risk of adverse effects.</p>
</list-item>
<list-item><p>It is recommended that prospective randomized clinical trials be designed for patients with <sc>labc</sc>
who fail to respond to <sc>nact</sc>
so that more definitive treatment recommendations can be developed.</p>
</list-item>
</list>
</sec>
</div>
</front>
</TEI>
<pmc article-type="research-article"><pmc-comment>The publisher of this article does not allow downloading of the full text in XML form.</pmc-comment>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Curr Oncol</journal-id>
<journal-id journal-id-type="iso-abbrev">Curr Oncol</journal-id>
<journal-id journal-id-type="publisher-id">CO</journal-id>
<journal-title-group><journal-title>Current Oncology</journal-title>
</journal-title-group>
<issn pub-type="ppub">1198-0052</issn>
<issn pub-type="epub">1718-7729</issn>
<publisher><publisher-name>Multimed Inc.</publisher-name>
<publisher-loc>66 Martin St. Milton, ON, Canada L9T 2R2</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">25848339</article-id>
<article-id pub-id-type="pmc">4381791</article-id>
<article-id pub-id-type="doi">10.3747/co.22.2316</article-id>
<article-id pub-id-type="publisher-id">conc-22-s54</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Practice Guideline</subject>
</subj-group>
</article-categories>
<title-group><article-title>Locoregional therapy of locally advanced breast cancer: a clinical practice guideline</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Brackstone</surname>
<given-names>M.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="af1-conc-22-s54"><sup>*</sup>
</xref>
<xref ref-type="corresp" rid="c1-conc-22-s54"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Fletcher</surname>
<given-names>G.G.</given-names>
</name>
<degrees>MSc</degrees>
<xref ref-type="aff" rid="af2-conc-22-s54"><sup>†</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Dayes</surname>
<given-names>I.S.</given-names>
</name>
<degrees>MD, MSc</degrees>
<xref ref-type="aff" rid="af3-conc-22-s54"><sup>‡</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Madarnas</surname>
<given-names>Y.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="af4-conc-22-s54"><sup>§</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>SenGupta</surname>
<given-names>S.K.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="af5-conc-22-s54"><sup>‖</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Verma</surname>
<given-names>S.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="af6-conc-22-s54"><sup>#</sup>
</xref>
</contrib>
<contrib contrib-type="author"><collab>Members of the Breast Cancer Disease Site Group</collab>
<xref ref-type="aff" rid="af7-conc-22-s54"><sup>**</sup>
</xref>
</contrib>
</contrib-group>
<aff id="af1-conc-22-s54"><label>*</label>
Surgical Oncology, London Regional Cancer Program, London Health Sciences Centre; and Departments of Surgery and Oncology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON.</aff>
<aff id="af2-conc-22-s54"><label>†</label>
Program in Evidence-Based Care, Cancer Care Ontario; and Department of Oncology, McMaster University, Hamilton, ON.</aff>
<aff id="af3-conc-22-s54"><label>‡</label>
Juravinski Cancer Centre, Hamilton Health Sciences; and Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON.</aff>
<aff id="af4-conc-22-s54"><label>§</label>
Department of Oncology, Queen’s University, Kingston, ON.</aff>
<aff id="af5-conc-22-s54"><label>‖</label>
Cancer Centre of Southeastern Ontario, Kingston General Hospital; and Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON.</aff>
<aff id="af6-conc-22-s54"><label>#</label>
The Ottawa Hospital Cancer Centre; and Department of Medicine, Division of Medical Oncology, University of Ottawa, Ottawa, ON.</aff>
<aff id="af7-conc-22-s54"><label>**</label>
A. Eisen, S. Gandhi, C. Holloway, and M. Trudeau, Sunnybrook Health Sciences, Toronto, ON; P. Bedard, Princess Margaret Hospital, Toronto, ON; D. McCready, Princess Margaret Hospital, Toronto, ON; J. Semple, Women’s College Hospital, Toronto, ON; R. George, St. Michael’s Hospital, Toronto, ON; B. Meyers, Credit Valley Hospital, Mississauga, ON; B. Dhesy–Thind and L. Elavathil, Hamilton Health Sciences, Hamilton, ON; F. Perera and T. Vandenberg, London Health Sciences Centre, London, ON; R. Gupta and C. Hamm, Windsor Regional Cancer Program, Windsor Regional Hospital, Windsor, ON; O. Freedman, Durham Regional Cancer Centre, Lakeridge Health, Oshawa, ON; M. Mates, Cancer Centre of Southeastern Ontario, Kingston General Hospital, Kingston, ON; M. Clemons and S. Dent, The Ottawa Hospital Cancer Centre, Ottawa, ON.</aff>
<author-notes><corresp id="c1-conc-22-s54">Correspondence to: Muriel Brackstone, c/o Program in Evidence-Based Care, McMaster University, Juravinski Hospital, G Wing, 2nd Floor, 1280 Main Street West, Hamilton, Ontario L8S 4L8. E-mail: <email>ccopgi@mcmaster.ca</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><month>3</month>
<year>2015</year>
</pub-date>
<volume>22</volume>
<issue>Suppl 1</issue>
<fpage>S54</fpage>
<lpage>S66</lpage>
<permissions><copyright-statement>Copyright © 2015 Multimed Inc.</copyright-statement>
<copyright-year>2015</copyright-year>
</permissions>
<abstract><sec><title>Questions</title>
<list list-type="order"><list-item><p>In female patients with locally advanced breast cancer (<sc>labc</sc>
) and good response to neoadjuvant chemotherapy (<sc>nact</sc>
), including endocrine therapy, what is the role of breast-conserving surgery (<sc>bcs</sc>
) compared with mastectomy?</p>
</list-item>
<list-item><p>In female patients with <sc>labc</sc>
,
<list list-type="alpha-lower"><list-item><p>is radiotherapy (<sc>rt</sc>
) indicated for those who have undergone mastectomy?</p>
</list-item>
<list-item><p>does locoregional <sc>rt</sc>
, compared with breast or chest wall <sc>rt</sc>
alone, result in a higher survival rate and lower recurrence rates?</p>
</list-item>
<list-item><p>is <sc>rt</sc>
indicated for those achieving a pathologic complete response (p<sc>cr</sc>
) to <sc>nact</sc>
?</p>
</list-item>
</list>
</p>
</list-item>
<list-item><p>In female patients with <sc>labc</sc>
who receive <sc>nact</sc>
, is the most appropriate axillary staging procedure sentinel lymph node biopsy (<sc>slnb</sc>
) or axillary dissection? Is <sc>slnb</sc>
indicated before <sc>nact</sc>
rather than at the time of surgery?</p>
</list-item>
<list-item><p>How should female patients with <sc>labc</sc>
that does not respond to initial <sc>nact</sc>
be treated?</p>
</list-item>
</list>
</sec>
<sec><title>Methods</title>
<p>This guideline was developed by Cancer Care Ontario’s Program in Evidence-Based Care (<sc>pebc</sc>
) and the Breast Cancer Disease Site Group (<sc>dsg</sc>
). A systematic review was prepared based on literature searches conducted using the <sc>medline</sc>
and <sc>embase</sc>
databases for the period 1996 to December 11, 2013. Guidelines were located from that search and from the Web sites of major guideline organizations. The working group drafted recommendations based on the systemic review. The systematic review and recommendations were then circulated to the Breast Cancer <sc>dsg</sc>
and the <sc>pebc</sc>
Report Approval Panel for internal review; the revised document underwent external review. The full three-part evidence series can be found on the Cancer Care Ontario Web site.</p>
</sec>
<sec><title>Recommendations</title>
<list list-type="bullet"><list-item><p>For most patients with <sc>labc</sc>
, modified radical mastectomy should be considered the standard of care. For some patients with noninflammatory <sc>labc</sc>
, <sc>bcs</sc>
can be considered on a case-by-case basis when the surgeon deems that the disease can be fully resected and the patient expresses a strong preference for breast preservation.</p>
</list-item>
<list-item><p>For patients with <sc>labc</sc>
, <sc>rt</sc>
after mastectomy is recommended.</p>
</list-item>
<list-item><p>It is recommended that, after <sc>bcs</sc>
or mastectomy, patients with <sc>labc</sc>
receive locoregional <sc>rt</sc>
encompassing the breast or chest wall and local node-bearing areas.</p>
</list-item>
<list-item><p>It is recommended that postoperative <sc>rt</sc>
remain the standard of care for patients with <sc>labc</sc>
who achieve p<sc>cr</sc>
to <sc>nact</sc>
.</p>
</list-item>
<list-item><p>It is recommended that axillary dissection remain the standard of care for axillary staging in <sc>labc</sc>
, with the judicious use of <sc>slnb</sc>
in patients who are advised of the limitations of the current data.</p>
</list-item>
<list-item><p>Although <sc>slnb</sc>
either before or after <sc>nact</sc>
is technically feasible, the data are insufficient to make any recommendation about the optimal timing of <sc>slnb</sc>
with respect to <sc>nact</sc>
. Limited data suggest higher sentinel lymph node identification rates and lower false negative identification rates when <sc>slnb</sc>
is conducted before <sc>nact</sc>
; however, those data must be balanced against the requirement for two operations if <sc>slnb</sc>
is not performed at the time of resection of the main tumour.</p>
</list-item>
<list-item><p>It is recommended that patients receiving neoadjuvant anthracycline–taxane-based therapy (or other sequential regimens) whose tumours do not respond to the initial agent or agents, or who experience disease progression, be expedited to the next agent or agents of the regimen.</p>
</list-item>
<list-item><p>For patients who, in the opinion of the treating physician, fail to respond or progress on first-line <sc>nact</sc>
, several therapeutic options can be considered, including second-line chemotherapy, hormonal therapy (if appropriate), <sc>rt</sc>
, or immediate surgery (if technically feasible). Treatment should be individualized through discussion at a multidisciplinary case conference, considering tumour characteristics, patient factors and preferences, and risk of adverse effects.</p>
</list-item>
<list-item><p>It is recommended that prospective randomized clinical trials be designed for patients with <sc>labc</sc>
who fail to respond to <sc>nact</sc>
so that more definitive treatment recommendations can be developed.</p>
</list-item>
</list>
</sec>
</abstract>
<kwd-group><kwd>Locally advanced breast cancer</kwd>
<kwd><sc>labc</sc>
</kwd>
<kwd>locoregional disease</kwd>
<kwd>radiotherapy</kwd>
<kwd><sc>slnb</sc>
</kwd>
<kwd>mastectomy</kwd>
<kwd>neoadjuvant chemotherapy</kwd>
<kwd>pathologic complete response</kwd>
</kwd-group>
</article-meta>
</front>
</pmc>
</record>
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