Aydah AlAwadhi, Consultant Medical Oncologist and Division Chair of Hematology and Oncology Department at Sheikh Shakbout Medical City, Abu Dhabi, shared a post on LinkedIn:
“Key updates of NCCN Breast Cancer guidelines v5.2025:
1. Axillary Management
- SLNB can be omitted in selected low-risk patients ≥70y with HR+/HER2– pT1 cN0 (Choosing Wisely).
- SOUND trial incorporated → SLNB may be omitted if axillary US is negative, HR+ HER2 -, pT1N0.
- DCIS → No routine SLNB unless: mastectomy, suspicion of invasion, or when future SLNB would be compromised.
- Repeat SLNB in local breast recurrence is allowed after previous SLNB or mastectomy. (limited data but now acknowledged) In patients with ALND and mastectomy, repeat SLNB with lymphoscintigraphy maybe considered rather than ALND.
2. Diagnosis and Biomarker Updates
- Baseline lymphedema assessment added to diagnostic workup.
- HER2 IHC 0 vs 0+ now defined as clinically meaningful—may influence therapy selection.
3. Metastatic/Advanced Disease
- T-DXd downgraded from Category 1 Preferred → Category 2A Other Recommended for second line HER2 IHC 0+
- Dato-DXd added (Category 2A) for metastatic ER+, HER2-0/1+/2–ISH– in 2nd or subsequent line therapy for those who have received prior endocrine therapy and chemotherapy.
- Imlunestrant added for post-AI ± CDK4/6 progression (2A).
- Repotrectinib added for NTRK fusions; Erdafitinib for FGFR-altered tumors (2B).
- Oligometastatic SBRT → new footnote stating no proven OS/PFS benefit.
- FES-PET/CT added for ER+ lobular when useful.
- New survivorship section specifically for metastatic patients.
4. Early Breast Cancer/Adjuvant Therapy
- Adjuvant ribociclib: Now Category 1 Preferred for high-risk HR+/HER2– EBC (3 years).
- Adjuvant abemaciclib: Remains Category 1 Preferred for monarchE-defined high risk.
- HER2+ early disease pathway updated for pT1c–pT3 adjuvant chemo + trastuzumab (Category 1) ± pertuzumab (pT2-pT3).
- TNBC, use of adjuvant pembrolizumab: Footnote removed; use becomes more individualized.”
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