2010NCCN指南-乳腺癌检查

Continue NCCN Clinical Practice Guidelines in Oncology™ Breast Cancer Screening and Diagnosis V.1.2010 www.nccn.org Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis NCCN Breast Cancer Screening and Diagnosis Panel Members Benjamin O. Anderson, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Ermelinda Bonaccio, MD Roswell Park Cancer Institute Saundra Buys, MD Huntsman Cancer Institute at the University of Utah Therese B. Bevers, MD/Chair The University of Texas M. D. Anderson Cancer Center Mary B. Daly, MD, PhD Fox Chase Cancer Center Peter J. Dempsey, MD The University of Texas M. D. Anderson Cancer Center William B. Farrar, MD Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Irving Fleming, MD St. Jude Children's Research Hospital/University of Tennessee Health Sciences Center Judy E. Garber, MD, MPH Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center Þ Þ ¶ § ‡ § ¶ ¶ † † † Sara Shaw, MD City of Hope Mary Lou Smith, JD, MBA Patient Consultant Theodore N. Tsangaris, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Cheryl Williams, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Thomas Yan eelov, PhD § Vanderbilt-Ingram Cancer Center Gary Lyman, MD, MPH Duke Comprehensive Cancer Center Elizabeth Rafferty, MD § Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center k † ‡ ¥ § ¶ § Randall E. Harris, MD, PhD Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Alexandra S. Heerdt, MD, FACS Memorial Sloan-Kettering Cancer Center Mark Helvie, MD University of Michigan Comprehensive Cancer Center Þ ¶ Þ § � � § ¶ John G. Huff, MD Vanderbilt-Ingram Cancer Center Nazanin Khakpour, MD H. Lee Moffitt Cancer Center & Research Institute Seema A. Khan, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Helen Krontiras, MD University of Alabama at Birmingham Comprehensive Cancer Center ¶ * § Radiologist/Radiotherapy/Radiation Oncology ¶ Surgery/Surgical Oncology † Medical Oncology ‡ Hematology/Hematology Oncology Þ Internist/Internal Medicine, including Family Practice, Preventive Management Pathology ¥ Patient Advocacy * Writing Committee Member � Continue NCCN Guidelines Panel Disclosure * * Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Table of Contents NCCN Breast Cancer Screening and Diagnosis Panel Members S History and Physical Examination (BSCR-1) Normal Risk, Screening / Follow Up (BSCR-1) Increased Risk, Screening / Follow Up (BSCR-2) Symptomatic, Positive Physical Findings (BSCR-4) Nipple Discharge, No Palpable Mass (BSCR-11) Asymmetric Thickening/Nodularity (BSCR-12) Skin Changes (BSCR-13) Mammographic Evaluation (BSCR-14) Breast Screening Considerations (BSCR-A) Risk Factors Used in the Modified Gail Model (BSCR-B) Assessment Category Definitions (BSCR-C) Guidelines Index Print the Breast Cancer Screening and Diagnosis Guideline ummary of Guidelines Updates � � � � � Dominant Mass, Age 30 Years (BSCR-5) Dominant Mass, Age < 30 Years (BSCR-9) � These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. For help using these documents, please click here Discussion References Clinical Trials: Categories of Evidence and Consensus:NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Summary of the Guidelines updates UPDATES Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Summary of changes in the 1.2010 version of the Breast Cancer Screening and Diagnosis Guidelines from the 2.2009 version include: General Added BI-RADS assessment categories with footnote “j” linking to BSCR-C where appropriate throughout the guideline. Added patient history to physical examination. Separated screening category of women 35 y or older with 5 y risk of invasive breast cancer greater than or equal to 1.7% from women who have a lifetime risk of greater than 20% based on models that are largely dependent on family history to clarify that consideration of annual MRI is only for women with a lifetime risk of greater than 20%. Added recommendation to consider referral to genetic counselor to the screening follow up for women with increased risk. Changed terminology from lump/mass to dominant mass. Footnote “n” is new to the page: “ ® � � � A complex cyst has both cystic and solid components.” Footnote “o” is new to the page: “Concordance is needed between clinical exam and ultrasound results. Consider therapeutic aspiration for persistent clinical symptoms.” BSCR-1 BSCR-2 BSCR-3 BSCR-5 BSCR-8 BSCR-12 BSCR-13 BSCR-15 BSCR-C Added a new pathway under aspirate findings for mass resolves and bloody fluid. Recommendation for women > 30 years with asymmetric thickening or nodularity was changed from “Mammogram +/- ultrasound” to “Mammogram + ultrasound.” Footnote “w” is new to the page: “A benign skin punch biopsy in a patient with a clinical suspicion of inflammatory breast cancer does not rule out malignancy. Further evaluation is recommended.” Changed the title of the page to “Assessment Category Definitions.” Included BI-RADS - Ultrasound assessment category definitions. Diagnostic mammogram follow-up: Recommendation changed from “Mammogram in 6-12 mo” to “Mammogram in 6-12 mo for 1-2 y.” � � ® Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SCREENING OR SYMPTOM CATEGORY History and physical examinationa Asymptomatic and Negative physical exam Symptomatic or Positive physical exam See Findings BSCR-4( ) Increased risk: Strong family history or genetic predisposition LCIS/Atypical hyperplasia Prior history of breast cancer b c d d e,f � � � � � � Prior thoracic RT (eg, mantle) 5-year risk of invasive breast cancer 1.7% in women 35 y Women who have a lifetime risk > 20% as defined by models that are largely dependent on family history � � See Increased Risk Screening Follow-up BSCR-2 BSCR-3)( , Normal risk a b c d e f Refer to the for a detailed qualitative and quantitative assessment. For a definition of strong family history, see As currently defined in the American Society of Clinical Oncology Policy Statement Update: Genetic testing for cancer susceptibility. J Clin Oncol 2003, 21:2397-2406. gWomen should be familiar with their breasts and promptly report changes to their healthcare provider. Periodic, consistent BSE may facilitate breast self awareness. Premenopausal women may find BSE most informative when performed at the end of menses. See Breast Screening Considerations BSCR-A NCCN Breast Cancer Risk Reduction Guidelines See Risk Factors Used in the Modified Gail Model BSCR-B NCCN Genetic/Familial High Risk Assessment Guidelines. See NCCN Genetic/Familial High Risk Assessment Guidelines. ( ). ( ). BSCR-1 Age 20 but < 40 y � Age 40 y� � � Clinical breast exam every 1-3 y Breast awarenessg � � � Annual clinical breast exam Annual mammogram Breast awarenessg SCREENING FOLLOW-UPa See Mammographic Evaluation (BSCR-14) Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Women 35 y with 5-year risk of invasive breast cancer 1.7%c � � Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SCREENING OR SYMPTOM CATEGORY SCREENING FOLLOW-UP Prior thoracic RT Age < 25 y Age 25 y� � � Annual clinical breast exam Breast awarenessg � � � Annual mammogram + clinical breast exam every 6-12 mo Begin 8-10 y after RT or age 25, whichever occurs last Consider annual breast MRI as an adjunct to mammogram and clinical breast exam Breast awareness � g Women who have a lifetime risk > 20% as defined by models that are largely dependent on family historyd � � � � Annual mammogram + clinical breast exam every 6-12 mo Breast awareness Consider risk reduction strategies ( ) Consider annual breast MRI g See NCCN Breast Cancer Risk Reduction Guidelines BSCR-2 c dFor a definition of strong family history, see See Risk Factors Used in the Modified Gail Model BSCR-B NCCN Genetic/Familial High Risk Assessment Guidelines. ( ). Increased Risk: See Physical Exam (BSCR-1) See Mammographic Evaluation (BSCR-14) gWomen should be familiar with their breasts and promptly report changes to their healthcare provider. Periodic, consistent BSE may facilitate breast self awareness. Premenopausal women may find BSE most informative when performed at the end of menses. � � � Annual mammogram + clinical breast exam every 6-12 mo Breast awareness Consider risk reduction strategies ( ) g See NCCN Breast Cancer Risk Reduction Guidelines Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Prior history of breast cancer See NCCN Breast Cancer Guidelines - Surveillance Section Strong family history or genetic predisposition d e,f Age < 25 yh Age 25 y� h � � � � � Annual mammogram + clinical breast exam every 6-12 mo Starting at age 25 y for Hereditary Breast and Ovarian Cancer (HBOC) patients 5-10 y prior to youngest breast cancer case for strong family history or other genetic predispositions Breast awareness Annual breast MRI as an adjunct to mammogram and clinical breast exam Consider risk reduction strategies ( ) Consider referral to genetic counselor � � f g See NCCN Breast Cancer Risk Reduction Guidelines LCIS/Atypical hyperplasia � � � � Annual mammogram + clinical breast exam every 6-12 mo Consider annual breast MRI for LCIS as an adjunct to mammogram and clinical breast exam Consider risk reduction strategies ( ) Breast awarenessg See NCCN Breast Cancer Risk Reduction Guidelines � � � Annual clinical breast exam Breast awareness Consider referral to genetic counselor g SCREENING OR SYMPTOM CATEGORY SCREENING FOLLOW-UP Increased Risk: Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. d e f For a definition of strong family history, see As currently defined in the American Society of Clinical Oncology Policy Statement Update: Genetic testing for cancer susceptibility. J Clin Oncol 2003, 21:2397-2406. NCCN Genetic/Familial High Risk Assessment Guidelines. See NCCN Genetic/Familial High Risk Assessment Guidelines. gWomen should be familiar with their breasts and promptly report changes to their healthcare provider. Periodic, consistent BSE may facilitate breast self awareness. Premenopausal women may find BSE most informative when performed at the end of menses. Earlier screening may be appropriate in some patients.h BSCR-3 See Physical Exam (BSCR-1) See Mammographic Evaluation (BSCR-14) Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Physical examination Symptomatic or positive findings on physical exam PRESENTING SIGNS/SYMPTOMS Dominant mass Nipple discharge, no palpable mass Asymmetric thickening/nodularity Skin changes: Erythema Nipple excoriation Scaling, eczema � � � Peau d’orange � Age < 30 y Age 30 y� See Follow-up Evaluation (BSCR-9) See Follow-up Evaluation (BSCR-5) See Diagnostic Follow-up (BSCR-11) See Diagnostic Follow-up (BSCR-12) See Diagnostic Follow-up (BSCR-13) BSCR-4 Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Increase in size Stable See Aspirate Findings BSCR-8( ) INITIAL EVALUATION FOLLOW-UP EVALUATION Ultrasound Solid No ultrasonographic abnormality BI-RADS category 1 ® j Tissue biopsy or Observe every 3-6 mo ± imaging for 1-2 y to assess stability Dominant mass Age 30 y� Mammogrami BI-RADS® Category 1-3j,k BI-RADS Category 4-5 ® j,k,l See Diagnostic Mammogram Follow-Up (BSCR-15) Probably benign finding BI-RADS category 3® j Suspicious or highly suggestive finding BI-RADS category 4-5® j See Ultrasound Findings (BSCR-7) Image guided biopsy or Surgical excision There are a few clinical circumstances in which ultrasound would be preferred (eg, suspected simple cyst). Mammography results are mandated to be reported using Final Assessment categories (Mammography Quality Standards Act, Final Rule. Federal Register 62(208):55988,1997). Assess geographic correlation between clinical and imaging findings. If there is a lack of correlation return to Category 1-3 for further work-up of palpable lesion. If imaging findings correlate with the palpable finding, workup of the imaging problem will answer the palpable problem. A complex cyst has both cystic and solid components. i j k l n m o Round, circumscribed mass containing low level echoes without vascular flow, fulfilling most but not all criteria for simple cyst. Concordance is needed between clinical exam and ultrasound results. Consider therapeutic aspiration for persistent clinical symptoms. See Assessment Category Definitions BSCR-C( ). PRESENTING SIGNS/SYMPTOMS AGE 30 yDOMINANT MASS / � Non-simple cyst Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. BSCR-5 Progression or enlargement on clinical exam Stable See Routine Screening (BSCR-1) See Tissue Biopsy BSCR-6 Complicatedm Complexn Short term follow-up Aspiration See Tissue Biopsy BSCR-6 Physical exam and ultrasound mammogram every 6-12 mo for 1-2 y to assess stability ± Simple cysto BI-RADS category 2® j See Routine Screening (BSCR-1) See Tissue Biopsy (BSCR-6) See Routine Screening (BSCR-1) BI-RADS category 4® j BI-RADS category 3 ® j Guidelines Index Breast Screening TOC Discussion, References Version 1.2010, 11/03/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Practice Guidelines in Oncology – v.1.2010NCCN ® Breast Cancer Screening and Diagnosis Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Solid: Suspicious or highly suggestive finding BI-RADS category 4-5 ® j Tissue biopsy ULTRASOUND FINDINGS DOMINANT MASS / AGE 30 y� See NCCN Breast Cancer Guidelines Excision (if core needle biopsy not possible) or FOLLOW-UP EVALUATION Benign and image concordant � � � � � Indeterminate or Atypical hyperplasia or LCIS Other Benign and image discordant q q r or Surgical excision Malignant See Routine Screening (BSCR-1)Benign Malignant Atypical hyperplasia LCIS Physical exam ± ultrasound/mammogram every 6-12 mo for 1-2 y to assess stability See Routine Screening (BSCR-1) NCCN Breast Cancer Risk Reduction Guidelines and Malignant See NCCN Breast Cancer Guidelines See Routine Screening (BSCR-1)Benign LCIS Atypical hyperplasia See Routine Screening (BSCR-1) NCCN Breast Cancer Risk Reduction Guidelines and Return to Lump/mass, Age 30 y, Initial Evaluation BSCR-5� ( ) j q p r FNA and core (needle or vacuum-assisted) biopsy are both valuable. FNA requir