January 27, 2023

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2021 NCCN Breast Cancer Guidelines Important Update Highlights

2021 NCCN Breast Cancer Guidelines Important Update Highlights


2021 NCCN Breast Cancer Guidelines Important Update Highlights.


In the first half of 2021, the NCCN breast cancer guidelines have been updated to version 5.

This article will summarize the updated contents of the guidelines in the first half of 2021 compared with the 2020 guidelines.


Neoadjuvant/adjuvant therapy


Point 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 with 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- preoperative chemotherapy for breast cancer, If the disease remains and the CPS+EG score is ≥3, adjuvant olaparib should also be considered for 1 year.

*The treatment of gBRCA-mutated HER2-negative breast cancer with olaparib has not been approved in China. The content of this information is not to be used as a treatment or recommendation for use.

The currently approved indication in China is for carrying germline or somatic BRCA mutations (gBRCAm). Or sBRCAm) advanced epithelial ovarian cancer, fallopian tube cancer or primary peritoneal cancer newly treated adult patients with maintenance treatment after first-line platinum-containing chemotherapy achieves complete remission or 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 has failed previous treatment (including a new endocrine drug) Adult patients with castration-resistant prostate cancer.


Point 2

Pre-menopausal pT1-3 and pN0 HR+/HER2-patients have adjusted their treatment options. 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 + ovarian based on the prognosis assessment of genetic testing inhibition;

Postmenopausal patients with pT1-3 and pN0 or pN+HR+/HER2-Adjuvant treatment stratification revised to 21 genes RS≥26 and RS<26; RS<26 patients are recommended to receive adjuvant endocrine therapy, RS≥26 patients are recommended to receive adjuvant chemotherapy sequential endocrine treat.


Point 3

For premenopausal patients who have received aromatase inhibitor therapy for 5 years + ovarian suppression/oophorectomy, extended aromatase inhibitor therapy should be considered for 3-5 years; for postmenopausal patients receiving aromatase inhibitor adjuvant therapy (natural or Induced) patients, consider receiving adjuvant therapy with bisphosphonate or desulumab.


Point 4

Gene expression testing provides prognostic and treatment prediction information, supplementing T, N, M and biomarker information. 

Staging does not require the use of these measurement methods. 21 genetic testing (Oncotype Dx) is the preferred prognosis and chemotherapy benefit prediction method of the NCCN breast cancer team. 

Other prognostic gene expression tests can provide prognostic information, but the ability to predict the benefit of chemotherapy is unclear.


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 for patients >50 years old, the difference is 8 years The absolute difference of distant metastasis-free survival was 0.2%±2.3%. 

Whether the chemotherapy benefit of women ≤50 years old is related to the suppression of ovarian function caused by chemotherapy is unclear.


Point 6

For patients with 1-3 positive axillary lymph nodes and meet the “ACOSOG Z0011 research criteria”, WBRT ± boost is recommended (local lymph node radiotherapy with or without axillary is determined by the radiotherapist). (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. (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, and post-mastectomy radiotherapy may be considered .



Late rescue treatment


Point 8

“Pembrolizumab + chemotherapy (albumin combined with paclitaxel, paclitaxel, gemcitabine and carboplatin)” is newly added to the first-line first-line choice for advanced triple-negative breast cancer. The patient is PD-L1 positive (CPS score> 10 points).


Point 9

The first-line preferred 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 preferred option can be used for second-line and subsequent treatment. If PD-L1 inhibitor treatment is in progress If the disease progresses, there is no data to support the use of another PD-L1 inhibitor for treatment.”


Point 10

Newly added, tucatinib + trastuzumab + capecitabine is the first choice for treatment of systemic and CNS after HER2-positive advanced enmetrastuzumab treatment, and can be used in second-line treatment.


Point 11

After the first-line treatment of HER2-positive advanced breast cancer is effective, use trastuzumab/pertuzumab maintenance therapy (if the patient has ER+HER2+ metastatic breast cancer, endocrine therapy is also given);

Add Margetuximab-cmkb+ chemotherapy (capecitabine, eribulin, gemcitabine or vinorelbine) to the optional third-line treatment of HER2-positive advanced breast cancer.




[1].NCCN Guidelines Version 5.2021 Breast Cancer.

2021 NCCN Breast Cancer Guidelines Important Update Highlights

(source:internet, reference only)

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