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In 2008, an estimated 184,450 new cases of breast cancer will occur in the United States.1 In the same year, it is estimated that almost 41,000 women will die of breast cancer. These numbers demonstrate the impact of breast cancer among American women, but they cannot begin to address the diversity and complexity of the treatment of this malignancy. As research and advances in the care of the breast cancer patient occur, the need for greater understanding of the tenets and principles of clinical decision-making in the treatment of breast cancer increases.

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In 1995, the National Comprehensive Cancer Network (NCCN) was developed in order to respond to the challenges of treating the most common cancers through clinical practice guidelines that delineated treatment through nonbiased, methodical algorithms. Based upon the Institute of Medicine's definition, which described guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances," the NCCN established a guideline program that proceeds as follows: comprehensive literature review by NCCN staff, development of prototype guidelines, review by site-specific panels, further analysis and clarification of guidelines, assessment by each NCCN member institution, collation of institutional review suggestions and issues, appraisal of the complete version of the guidelines by the NCCN Guidelines Steering Committee, and final approval by the NCCN Board of Directors. The guidelines are subsequently reviewed annually by the panel chair and 3 other multidisciplinary members to determine if further revisions are necessary. This chapter discusses the guidelines set forth by the NCCN regarding the treatment of primary invasive breast cancer (Figs. 82-1, 82-2, 82-3 and 82-4).

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Figure 82-1
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Algorithm of NCCN guidelines for the treatment of hormone receptor–positive, HER-2-positive breast cancer. [Reproduced with permission from The NCCN (2.2008) Invasive Breast Cancer. Clinical Practice Guidelines in Oncology. © National Comprehensive Cancer Network, 2008. Available at: http://www.nccn.org. To view the most recent and complete version of the guideline, go online to www.nccn.org.]

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Figure 82-2
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Algorithm of NCCN guidelines for the treatment of hormone receptor–positive, HER-2-negative breast cancer. [Reproduced with permission from The NCCN (2.2008) Invasive Breast Cancer. Clinical Practice Guidelines in Oncology. © National Comprehensive Cancer Network, 2008. Available at: http://www.nccn.org. To view the most recent and complete version of the guideline, go online to www.nccn.org.]

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Figure 82-3
Graphic Jump Location

Algorithm of NCCN guidelines for the treatment of hormone receptor–negative, HER-2-positive breast cancer. [Reproduced with permission from The NCCN (2.2008) Invasive Breast Cancer. Clinical Practice Guidelines in Oncology. © National Comprehensive Cancer Network, 2008. Available at: http://www.nccn.org. To view the most recent and complete version of the guideline, go online to www.nccn.org.]

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