Breast Cancer

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November 28, 2017

Volume 9 • Issue 24

Search past NCCN eBulletins

FEATURED ARTICLES

Multistakeholder Clinician Group

NCCN, in Collaboration with Pfizer, Awards Nine Grants for Quality Improvement in Breast Cancer Care

Giving Tuesday_small

Make a Difference for Patients with Cancer this #GivingTuesday!
 
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Climbing Costs for Treating Breast Cancer Poised to Strain Medicare in the Near Future

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NCCN GUIDELINES® UPDATES

NCCN Flash Update: NCCN Guidelines® for Anemia 
November 22, 2017

NCCN Flash Update: NCCN Guidelines®, NCCN Compendium®, NCCN Templates®, & NCCN Radiation Therapy Compendium® for NSCLC  
November 22, 2017 

 

NCCN Flash Updates: NCCN Guidelines®, NCCN Compendium®, & NCCN Templates® for Breast Cancer 
November 17, 2017 

NCCN Flash Update: NCCN Guidelines® for B-Cell Lymphomas & Colorectal Cancer Screening 
November 16, 2017 

 

UPCOMING EVENTS

This Friday! December 1,  2017  • Washington, DC

NCCN Patient Advocacy Summit: Addressing Survivorship in Cancer Care


Friday, February 9,  2018  • Chicago, IL
NCCN 2018 Congress Series™: Breast Cancer with Updates from the 2017 San Antonio Breast Cancer Symposium 

Save the Date! NCCN Annual Conference: Improving the Quality, Effectiveness, and Efficiency of Cancer Care™
Thursday, March 22 – Saturday, March 24, 2018  
Rosen Shingle Creek • Orlando, Florida 

Pre-Conference Activities take place on Wednesday, March 21, 2018: 

NCCN Nursing Program: Advancing Oncology Nursing™
NCCN Academy for Excellence & Leadership in Oncology™ 

UPCOMING WEBINARS

Monthly Oncology Tumor Boards: 

A Multidisciplinary Approach to Individualized Care 

Friday, December 15, 2017 • 11:00 AM – 12:00 PM EST
Lung Cancer: Advanced Disease 

Tuesday, January 24, 2018 • 12:00 – 1:00 PM EST
Lung Cancer: Early Stage Disease

2017 NCCN Oncology Case Manager and Medical Director Program™ Live Webinars

Thursday, November 30,  2017  • 12:00 – 1:15 PM EST
Updates in the Management of Breast Cancer 

Wednesday, December 13,  2017  • 12:00 – 1:15 PM EST
Transitioning from Patient with Cancer to Cancer Survivor 

NCCN 2017 Congress Webinar Series™: Biomarkers 101 


Tuesday, December 5, 2017 • 12:00 – 1:00 PM EST
Which Biomarker Test Should I Use?

Wednesday, December 13,  2017  • 3:00 – 4:00 PM EST
Clinical Utility of Biomarkers

ONLINE LEARNING

Recorded Presentations from the NCCN 12th Annual Congress: Hematologic Malignancies™

Recorded Presentations from the NCCN 2017 Nursing Forum: 
Advancing Oncology Nursing in Hematologic Malignancies™
 

NCCN MEMBER INSTITUTIONS IN THE NEWS

Study Reveals New Mechanism Used by Cancer Cells to Disarm Attacking Immune Cells (The Ohio State University Comprehensive Cancer Center ‒ James Cancer Center and Solove Research Institute)

 > Risk for Aging-Related Diseases Elevated Among Thyroid Cancer Survivors (Huntsman Cancer Institute at the University of Utah)  

ABOUT NCCN

About NCCN > NCCN Annual Report > NCCN Guidelines® > NCCN Compendium® 
Educational Events > Publications > Online Catalog


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Oncoplastic Surgery for Breast Cancer

The Top Killer In Breast Cancer May Surprise You
 
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General Surgery News and www.generalsurgerynews.com/ are part of McMahon Publishing.

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New Issue
April 4, 2017
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In This Issue of JAMA
Highlights  
JAMA. 2017;317(13):1291 doi:10.1001/jama.2016.13064
Viewpoint
Prime Time for Shared Decision Making  
Erica S. Spatz, MD, MHS; Harlan M. Krumholz, MD, SM; Benjamin W. Moulton, JD, MPH
JAMA. 2017;317(13):1309 doi:10.1001/jama.2017.0616
Medical Liability Reform in a New Political Environment  
Anand Parekh, MD, MPH; G. William Hoagland, MS
JAMA. 2017;317(13):1311 doi:10.1001/jama.2017.1405
Making Health Care Markets Work: Competition Policy for Health Care  
Martin Gaynor, PhD; Farzad Mostashari, MD, ScM; Paul B. Ginsburg, PhD
JAMA. 2017;317(13):1313 doi:10.1001/jama.2017.1173
A Piece of My Mind
The Prescriptions I Write  
Norah Neylon, MBBS
JAMA. 2017;317(13):1315 doi:10.1001/jama.2016.16796
Editorial
Reevaluating Postnatal Steroids for Extremely Preterm Infants to Prevent Lung Disease  
Neil Marlow, DM, FMedSci
JAMA. 2017;317(13):1317 doi:10.1001/jama.2017.2725
Recreational Exercise in Hypertrophic Cardiomyopathy  
Anjali T. Owens, MD; Thomas P. Cappola, MD, ScM
JAMA. 2017;317(13):1319 doi:10.1001/jama.2017.2584
Original Investigation
Effect of Dexmedetomidine on Mortality and Ventilator-Free Days in Patients Requiring Mechanical Ventilation With Sepsis: A Randomized Clinical Trial  
Yu Kawazoe, MD, PhD; Kyohei Miyamoto, MD; Takeshi Morimoto, MD, PhD, MPH; et al
JAMA. 2017;317(13):1321 doi:10.1001/jama.2017.2088
Association Between Early Low-Dose Hydrocortisone Therapy in Extremely Preterm Neonates and Neurodevelopmental Outcomes at 2 Years of Age  
Olivier Baud, MD, PhD; Clémence Trousson, MSc; Valérie Biran, MD, PhD; et al
JAMA. 2017;317(13):1329 doi:10.1001/jama.2017.2692
Trends in Thyroid Cancer Incidence and Mortality in the United States, 1974-2013  
Hyeyeun Lim, PhD; Susan S. Devesa, PhD; Julie A. Sosa, MD; et al
JAMA. 2017;317(13):1338 doi:10.1001/jama.2017.2719
Preliminary Communication
Effect of Moderate-Intensity Exercise Training on Peak Oxygen Consumption in Patients With Hypertrophic Cardiomyopathy: A Randomized Clinical Trial  
Sara Saberi, MD, MS; Matthew Wheeler, MD, PhD; Jennifer Bragg-Gresham, MS, PhD; et al
JAMA. 2017;317(13):1349 doi:10.1001/jama.2017.2503
Editorial: Recreational Exercise in Hypertrophic Cardiomyopathy; Anjali T. Owens, MD; Thomas P. Cappola, MD, ScM
Review
Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment  
Matthew E. Hirschtritt, MD, MPH; Michael H. Bloch, MD, MS; Carol A. Mathews, MD
JAMA. 2017;317(13):1358 doi:10.1001/jama.2017.2200
From The JAMA Network
Congenital Zika Syndrome in 2017  
Daniel Lucey, MD, MPH; Hannah Cummins, MS; Sabrina Sholts, PhD
JAMA. 2017;317(13):1368 doi:10.1001/jama.2017.1553
JAMA Clinical Challenge
Fever in a Traveler Returning From Africa  
Erica S. Herc, MD; David Manthei, MD, PhD; James Riddell IV, MD
JAMA. 2017;317(13):1370 doi:10.1001/jama.2016.19729
Research Letter
Rates of Cortical Atrophy in Adults 80 Years and Older With Superior vs Average Episodic Memory  
Amanda H. Cook, MA; Jaiashre Sridhar, MS; Daniel Ohm, BS; et al
JAMA. 2017;317(13):1373 doi:10.1001/jama.2017.0627
Comment & Response
Rate of Persistent Postconcussive Symptoms  
Garrett R. Young, BA; Jack W. Tsao, MD, DPhil
JAMA. 2017;317(13):1375 doi:10.1001/jama.2017.1322
Rates of Persistent Postconcussive Symptoms  
Roger L. Zemek, MD; Keith Owen Yeates, PhD
JAMA. 2017;317(13):1375 doi:10.1001/jama.2017.1327
Interventions for Anxiety and Depression in Conflict-Affected Areas  
Ka Yiu Lee, PhD; Michael Huen Sum Lam, PhD; Yazhuo Deng, MSc
JAMA. 2017;317(13):1376 doi:10.1001/jama.2017.1842
Interventions for Anxiety and Depression in Conflict-Affected Areas—Reply  
Atif Rahman, PhD; Mark van Ommeren, PhD; Saeed Farooq, PhD
JAMA. 2017;317(13):1376 doi:10.1001/jama.2017.1848
The Right to Health Care  
Joshua D. Lenchus, DO, RPh
JAMA. 2017;317(13):1377 doi:10.1001/jama.2017.1863
Research on Gun Violence vs Other Causes of Death  
Lavi Oud, MD
JAMA. 2017;317(13):1378 doi:10.1001/jama.2017.2428
The Right to Health Care  
Howard Bauchner, MD
JAMA. 2017;317(13):1378 doi:10.1001/jama.2017.1866
Research on Gun Violence vs Other Causes of Death  
David E. Stark, MD, MS; Nigam H. Shah, MBBS, PhD
JAMA. 2017;317(13):1379 doi:10.1001/jama.2017.2440
Medical News & Perspectives
Resetting the Circadian Clock Might Boost Metabolic Health  
Bridget M. Kuehn
JAMA. 2017;317(13):1303 doi:10.1001/jama.2017.0653
The JAMA Forum
Vaccines and the Trump Administration  
Joshua M. Sharfstein, MD
JAMA. 2017;317(13):1305 doi:10.1001/jama.2017.2311
Lab Reports
Allele-Specific Gene Expression May Influence Mental Health  
Tracy Hampton, PhD
JAMA. 2017;317(13):1307 doi:10.1001/jama.2017.2529
Circadian Clock Boosts Stress-Response Genes During Aging  
Tracy Hampton, PhD
JAMA. 2017;317(13):1307 doi:10.1001/jama.2017.3108
Skin’s Natural Bacteria May Protect Against Pathogens  
Tracy Hampton, PhD
JAMA. 2017;317(13):1307 doi:10.1001/jama.2017.3111
News From the Food and Drug Administration
Biologic Medication for Psoriasis  
Rebecca Voelker, MSJ
JAMA. 2017;317(13):1308 doi:10.1001/jama.2017.2408
Detecting Bacteremia Pathogens  
Rebecca Voelker, MSJ
JAMA. 2017;317(13):1308 doi:10.1001/jama.2017.2683
Test Aids Antibiotic Decisions  
Rebecca Voelker, MSJ
JAMA. 2017;317(13):1308 doi:10.1001/jama.2017.2685
The Arts and Medicine
How to Survive a Plague: The Next Great HIV/AIDS History  
Paul A. Volberding, MD
JAMA. 2017;317(13):1298 doi:10.1001/jama.2017.1325
Poetry and Medicine
Fire, in the Kingdom of Animals  
Ian Wicks, MB, BS, FRACP, PhD
JAMA. 2017;317(13):1380 doi:10.1001/jama.2016.18401
JAMA Revisited
Ehrlich and Von Behring  
JAMA. 2017;317(13):1381 doi:10.1001/jama.2017.0642
JAMA Patient Page
Vaginal and Urinary Symptoms of Menopause  
Jill Jin, MD, MPH
JAMA. 2017;317(13):1388 doi:10.1001/jama.2017.0833
JAMA Masthead
JAMA 
JAMA. 2017;317(13):1295 doi:10.1001/jama.2016.13065
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Think PERJETA Before Surgery
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for treatment of breast cancer before surgery
NCCN Guidelines® recommend a pertuzumab (PERJETA®) and trastuzumab (Herceptin®) combination-based neoadjuvant regimen as an option for the treatment of HER2-positive (HER2+) early-stage breast cancer (category 2A)1
Based upon lower-level evidence, there is uniform National Comprehensive Cancer Network® (NCCN®) consensus that the intervention is appropriate (category 2A).
See more details ›
Consider consulting a medical oncologist: Targeted treatment with a PERJETA and Herceptin combination- based regimen may help your patients before surgery.
Indication
PERJETA® (pertuzumab) is a HER2/neu receptor antagonist indicated for use in combination with Herceptin®(trastuzumab) and docetaxel as neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer. This indication is based on demonstration of an improvement in pathological complete response rate. No data are available demonstrating improvement in event-free survival or overall survival.
Limitations of Use:
The safety of PERJETA as part of a doxorubicin-containing regimen has not been established
The safety of PERJETA administered for greater than 6 cycles for early breast cancer has not been established
References:
1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed July 30, 2016. To view the most recent and complete version of the guideline, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.
Important Safety Information
Boxed WARNINGS: Left Ventricular Dysfunction and Embryo-Fetal Toxicity
PERJETA administration can result in subclinical and clinical cardiac failure manifesting as decreased LVEF and CHF. Evaluate cardiac function prior to and during treatment. Discontinue PERJETA treatment for a confirmed clinically significant decrease in left ventricular function
Exposure to PERJETA can result in embryo-fetal death and birth defects. Advise patients of these risks and the need for effective contraception
Verify the pregnancy status of females of reproductive potential prior to the initiation of PERJETA. Advise pregnant women and females of reproductive potential that exposure to PERJETA in combination with trastuzumab during pregnancy or within 7 months prior to conception can result in fetal harm, including embryo-fetal death or birth defects. Advise females of reproductive potential to use effective contraception during treatment and for 7 months following the last dose of PERJETA in combination with trastuzumab
There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to PERJETA during pregnancy. Encourage women who receive PERJETA in combination with trastuzumab during pregnancy or within 7 months prior to conception, to enroll in the MotHER Pregnancy Registry by contacting 1‑800‑690‑6720 or visiting http://www.motherpregnancyregistry.com/
If PERJETA is administered during pregnancy, or if a patient becomes pregnant while receiving PERJETA or within 7 months following the last dose of PERJETA in combination with trastuzumab, health care providers and patients should immediately report PERJETA exposure to Genentech at 1‑888‑835‑2555
Additional Important Safety Information
PERJETA is contraindicated in patients with known hypersensitivity to pertuzumab or to any of its excipients.
Left Ventricular Dysfunction (LVD)
In Study 1, for patients with MBC, left ventricular dysfunction, which includes symptomatic left ventricular systolic dysfunction (LVSD) (congestive heart failure) and decreases in left ventricular ejection fraction (LVEF), occurred in 4.4% of patients in the PERJETA-treated group and in 8.3% of patients in the placebo-treated group
In Study 2, for patients receiving neoadjuvant treatment, the incidence of LVSD was higher in PERJETA-treated groups than in the trastuzumab and docetaxel group. An increased incidence of LVEF declines was observed in patients treated with PERJETA in combination with trastuzumab and docetaxel. In the overall treatment period, LVEF decline >10% and a drop to less than 50% occurred in 1.9% of patients treated with neoadjuvant trastuzumab and docetaxel as compared to 8.4% of patients treated with neoadjuvant PERJETA in combination with trastuzumab and docetaxel
In Study 3, for patients receiving neoadjuvant treatment, in the overall treatment period, LVEF decline ˃10% and a drop to less than 50% occurred in 6.9% of patients treated with PERJETA plus trastuzumab and FEC followed by PERJETA plus trastuzumab and docetaxel, in 16.0% of patients treated with PERJETA plus trastuzumab and docetaxel following FEC, and in 10.5% of patients treated with PERJETA in combination with TCH
Assess LVEF prior to initiation of PERJETA and at regular intervals (eg, every 3 months in the metastatic setting and every 6 weeks in the neoadjuvant setting) during treatment to ensure that LVEF is within your institution’s normal limits
If LVEF is <45%, or is 45% to 49% with a 10% or greater absolute decrease below the pretreatment value, withhold PERJETA and trastuzumab and repeat LVEF assessment within approximately 3 weeks. Discontinue PERJETA and trastuzumab if LVEF has not improved or has declined further
Infusion-Associated Reactions
PERJETA has been associated with infusion reactions
In Study 1, when all drugs were administered on the same day, the most common infusion reactions in the PERJETA-treated group (≥1.0%) were fatigue, dysgeusia, hypersensitivity, myalgia, and vomiting
In Study 2 and Study 3, PERJETA was administered on the same day as the other study treatment drugs. Infusion reactions were consistent with those observed in Study 1, with a majority of reactions being National Cancer Institute - Common Terminology Criteria for Adverse Events (NCI‑CTCAE v3.0) Grades 1-2
If a significant infusion reaction occurs, slow or interrupt the infusion and administer appropriate medical therapies. Monitor patients carefully until complete resolution of signs and symptoms. Consider permanent discontinuation in patients with severe infusion reactions
Hypersensitivity Reactions/Anaphylaxis
In Study 1, the overall frequency of hypersensitivity/anaphylaxis reactions was 10.8% in the PERJETA-treated group and 9.1% in the placebo-treated group. The incidence of Grades 3-4 reactions was 2.0% and 2.5%, respectively, according to NCI-CTCAE (version 3)
In Study 2 and Study 3, hypersensitivity/anaphylaxis events were consistent with those observed in Study 1
Patients should be observed closely for hypersensitivity reactions. Severe hypersensitivity, including anaphylaxis, has been observed in clinical trials of PERJETA. Medications to treat such reactions, as well as emergency equipment, should be available for immediate use
HER2 Testing
Detection of HER2 protein overexpression is necessary for selection of patients appropriate for PERJETA therapy because these are the only patients studied and for whom benefit has been shown
Most Common Adverse Reactions
Neoadjuvant Treatment of Breast Cancer
The most common adverse reactions (>30%) with PERJETA in combination with trastuzumab and docetaxel were alopecia, diarrhea, nausea, and neutropenia. The most common NCI-CTCAE v3.0 Grades 3-4 adverse reactions (>2%) were neutropenia, febrile neutropenia, leukopenia, and diarrhea
The most common adverse reactions (>30%) with PERJETA in combination with trastuzumab and docetaxel when given for 3 cycles following 3 cycles of FEC were fatigue, alopecia, diarrhea, nausea, vomiting, and neutropenia. The most common NCI-CTCAE (version 3) Grades 3-4 adverse reactions (>2%) were neutropenia, leukopenia, febrile neutropenia, diarrhea, left ventricular dysfunction, anemia, dyspnea, nausea, and vomiting
The most common adverse reactions (>30%) with PERJETA in combination with docetaxel, carboplatin, and trastuzumab (TCH) for 6 cycles were fatigue, alopecia, diarrhea, nausea, vomiting, neutropenia, thrombocytopenia, and anemia. The most common NCI-CTCAE (version 3) Grades 3-4 adverse reactions (>2%) were neutropenia, febrile neutropenia, anemia, leukopenia, diarrhea, thrombocytopenia, vomiting, fatigue, ALT increased, hypokalemia, and hypersensitivity
You may report side effects to the FDA at 1‑800‑FDA‑1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at 1‑888‑835‑2555.
Please see additional select Important Safety Information throughout, and the accompanying full Prescribing Information, including Boxed WARNINGS.
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Genentech USA, Inc. 
1 DNA Way 
South San Francisco, CA 
94080-4990

 
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Survivorship

You’ve survived the shock of a breast cancer diagnosis, made decisions on treatments options, kept countless appointments, undergone procedures, and taken medications. You’ve finished your treatments for breast cancer. Now what? Learn more about where you go from here.

What you need to know about follow-up care

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Additional Topics

Breast Cancer Diagnosis

You hear the words, “I am sorry to tell you that you have breast cancer.”

What do I do next?

You’re left with questions: What do I do next? Will I need surgery…radiation…chemotherapy? Do I need other tests? What stage is my breast cancer? What are my options? Find answers to those and other questions you may have here.

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How to Prepare for Surgery

What you need to know.

You’ve met your surgeon. You need an operation. You also need answers to your growing list of questions: What should I expect? What questions should I ask? What should I do to get ready? Is there a checklist? Will I need special medications before surgery, after surgery? Will I need to make any special arrangements? Learn how you can make the process before, during, and after surgery easier for you and your family.

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