2021 NCCN and CSCO Breast Cancer Guidelines Update

*Only for medical professionals to read and refer to the updated points of the 2021 NCCN Breast Cancer Guidelines [1] The NCCN breast cancer guidelines have been updated to version 5 in the first half of 2021.
We will summarize the updated contents of the guidelines in the first half of 2021 compared with the 2020 guidelines
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Neoadjuvant/adjuvant treatment points 1 The first choice of neoadjuvant/adjuvant treatment for HER2-negative breast cancer is newly added olaparib (if gBRCA1/2 mutation is associated with high risk), and a footnote is added for patients with gBRCA1/2 mutation and high risk 1) TNBC and ≥pT2 or ≥pN1 (Class 1); or 2) Patients with HR+/HER2- ≥4 positive lymph nodes should consider adjuvant chemotherapy and add olaparib to adjuvant therapy for 1 year; for BRCA1/2 mutations and HR+HER2- breast Patients with preoperative chemotherapy for cancer, if the residual lesions and CPS+EG score ≥3, should also be considered for adjuvant olaparib treatment for 1 year
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*The treatment of gBRCA-mutated HER2-negative breast cancer with olaparib has not yet been approved in China.
Or sBRCAm) advanced epithelial ovarian cancer, fallopian tube cancer or primary peritoneal cancer newly treated adult patients with first-line platinum-containing chemotherapy to achieve complete remission or maintenance treatment after partial remission; platinum-sensitive recurrent epithelial ovarian cancer, fallopian tube cancer or Maintenance treatment for adult patients with primary peritoneal cancer after platinum-containing chemotherapy has achieved complete or partial remission; metastatic disease that carries germline or somatic BRCA mutations (gBRCAm or sBRCAm) and previous treatments (including a new endocrine drug) have failed Adult patients with castration-resistant prostate cancer
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Point 2 Pre-menopausal pT1-3 and pN0 HR+/HER2-patient treatment options are adjusted, patients who are not suitable for chemotherapy receive adjuvant endocrine therapy + ovarian suppression, and chemotherapy patients receive adjuvant chemotherapy sequential endocrine therapy or endocrine therapy based on the prognosis assessment of genetic testing + Ovarian suppression; postmenopausal pT1-3 and pN0 or pN+ HR+/HER2- patients with adjuvant treatment stratification modified to 21 genes RS≥26 and RS<26; RS<26 patients are recommended to receive adjuvant endocrine therapy, RS≥26 patients are recommended to assist Sequential endocrine therapy with chemotherapy
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Point 3 For premenopausal patients who have received aromatase inhibitor therapy for 5 years + ovarian suppression/oophorectomy, prolonged aromatase inhibitor therapy should be considered for 3-5 years; for postmenopausal patients receiving aromatase inhibitor adjuvant therapy ( Natural or induced) patients, consider adjuvant treatment with bisphosphonate or desulumab
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Point 4 Gene expression testing provides prognostic and treatment prediction information, supplementing T, N, M and biomarker information
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Staging does not require the use of these measurement methods
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21 gene testing (Oncotype Dx) is the preferred prognosis and chemotherapy benefit prediction method of the NCCN breast cancer team
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Other prognostic gene expression tests can provide prognostic information, but the ability to predict the benefit of chemotherapy is unclear
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Point 5: The effect of increasing 70 genes (MammaPrint) on treatment: For patients ≤50 years of age, the absolute difference in the 8-year metastasis-free survival of patients receiving chemotherapy is 5.
4%±2.
8%, while patients >50 years old The absolute difference of 8-year metastasis-free survival was 0.
2%±2.
3%
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Whether the benefit of chemotherapy in women ≤50 years old is related to the suppression of ovarian function caused by chemotherapy is unclear
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Key points: 61-3 patients with positive axillary lymph nodes who meet the "ACOSOG Z0011 research criteria" are recommended for WBRT ± boost (local lymph node radiotherapy with or without axilla is determined by the radiologist)
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(Class 1); For breast cancer patients 70 years of age and older who are ER-positive, cN0, T1, and receive adjuvant endocrine therapy, radiotherapy can be exempted
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(Class 1) Point 7 Breast cancer patients with a variety of characteristics of high risk of recurrence, including central zone/inner quadrant tumors or tumors> 2 cm with dissection <10 axillary lymph nodes and at least one of them is grade 3, ER negative or LVI.
Consider radiotherapy after mastectomy
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Advanced rescue treatment points 8 Advanced triple-negative breast cancer first-line first-line first-line option is newly added "Pembrolizumab + chemotherapy (albumin combined with paclitaxel, paclitaxel, gemcitabine and carboplatin)", the patient is PD-L1 positive (CPS score> 10 points )
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Point 9 The first-line first-line first-line option for advanced triple-negative breast cancer is newly added.
"Although the existing data are in the first-line, if you have not received PD-L1 inhibitor treatment in the past, the first-line first-line first-line option can be used for second-line and subsequent treatment
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If PD-L1 inhibitors If the disease progresses during treatment, there is no data to support the use of another PD-L1 inhibitor for treatment
.
”
Point 10 is newly added.
Tucatinib+trastuzumab+capecitabine is the first choice for the treatment of the systemic and CNS after HER2-positive advanced enmetrastuzumab treatment, and can be used in second-line treatment
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Key point 11 After the first-line treatment of HER2-positive advanced breast cancer is effective, use trastuzumab/pertuzumab as maintenance therapy (if the patient has ER+HER2+ metastatic breast cancer, simultaneously receive endocrine therapy); HER2-positive advanced breast cancer ≥ third-line therapy Add Margetuximab-cmkb+ chemotherapy (capecitabine, eribulin, gemcitabine or vinorelbine) to the optional program
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Key points of the 2021 CSCO breast cancer guidelines update [2] The 2021 version of the CSCO guidelines was officially updated and launched in April.
This update is more comprehensive.
Pathology detection, early neoadjuvant/adjuvant therapy and late rescue treatment are all involved.
Here we are To summarize this update of the main points
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Pathological examination points 1 A new definition of HER2 low expression is added, based on the fact that patients with low HER2 expression may benefit from the treatment of new antibody-conjugated drugs, and clinical studies are ongoing
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Therefore, on the basis of the original definition of HER2 negative in the clinic, patients with HER2 IHC 1+ or IHC2+ and ISH negative are defined as HER2 low expression, and an IHC result of 0 is defined as HER-2 negative
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Point 2 added ER weakly positive interpretation, 1%~10% of cell nuclei are stained as ER weakly positive (add a note when reporting, report the percentage of staining, the intensity and the expression of the control)
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Point 3 New evaluation of PD-L1 in breast cancer.
Clinical studies have shown that the expression level of PD-L1 may be related to the efficacy of PD-1/PD-L1 inhibitors.
The accurate evaluation of PD-L1 expression level will affect the subsequent treatment of patients
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Neoadjuvant Therapy Essentials 4 If the pCR stratification is not reached, the recommended level of trastuzumab + pertuzumab is adjusted from level II to level I, and the new "under the premise of a full course of treatment, if the tumor shrinks significantly (such as Miller) & Payne grade 3~4), the expert group tends to continue to use dual-targeted therapy, for tumor regression is not obvious (such as Miller & Payne grade 1~2), the expert group is more inclined to switch to T-DM1 treatment" Express
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Point 5 Neoadjuvant anti-HER2 therapy only uses trastuzumab.
In the pCR stratification, T-DM1 recommendation order prioritizes HP dual-targeted therapy adjuvant therapy
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Adjuvant treatment points 6: In the adjuvant treatment part of TNBC patients, high-risk patients are stratified (for those who meet any of the following conditions: lymph node positive; tumor> 2cm), the new "sequential capecitabine after chemotherapy (2A)" program is added
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Point 7: Axillary lymph nodes are negative but with high-risk factors.
The recommended treatment for "AC-TH" and "TCbH" is adjusted from 1A to 2A
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Treatment points for advanced rescue 8 The "Nelatinib + capecitabine (2B)" regimen was added to the level III recommendation for patients with trastuzumab treatment failure; the "trastuzumab combined chemotherapy" was adjusted to "H + chemotherapy" , Where H refers to "anti-HER2 monoclonal antibody, including trastuzumab and its biological analogues, and inituzumab that have been marketed in China"; in "TKI combined with other chemotherapeutic drugs", TKI includes pyrrotinib, lambda Patinib, Nelatinib
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Point 9: For patients with failed anthracycline therapy, a new "GP regimen" (1A) is recommended for level I; "albumin paclitaxel + PDI/PD-L1 inhibitor 5 (2A)" is recommended for level II; a new "albumin paclitaxel + PDI/PD-L1 inhibitor 5 (2A)" is recommended for level III.
Chemotherapy + PD-1 inhibitor (2B)” program
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References [1].
NCCN Guidelines Version 5.
2021 Breast Cancer.
[2].
CSCO Breast Cancer Guide 2021.
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