Diagnosis and treatment of early breast cancer

A summary of “Diagnosis and treatment of early breast cancer, including locally advanced disease—summary of NICE guidance” appears in a recent edition of the British Medical Journal (BMJ).

This is a long post but I believe this a crucial guide to anyone newly diagnosed with early breast cancer. It would be particularly beneficial to those trying to make decisions regarding adjuvant therapy. NICE recommendations are based on systematic reviews of best available evidence. The guideline includes a large spectrum of disease, ranging from ductal carcinoma in situ (DCIS) to inflammatory breast cancer, and also includes breast cancer in men, which is rare. It highlights again for me the absolute need for a multi-disciplinary approach to  planning breast cancer treatment for patients.

A summary of the recommendations are outlined below.

Diagnosis and preoperative assessment

• Magnetic resonance imaging (MRI) of the breast is not recommended as a routine preoperative assessment of patients with invasive breast cancer or DCIS but can help when a discrepancy exists between the clinical and radiological assessment, when breast density prevents mammographic assessment, or when breast conservation surgery to assess tumour size is being considered in lobular cancer.
• Ensure that pretreatment ultrasonography of the axilla is carried out and ultrasound guided needle biopsy also if abnormal lymph nodes are detected.

 Psychological support

• Members of the breast cancer clinical team should have completed an approved communication skills training programme.
• Allocate patients to a named breast care nurse specialist to support them throughout their care and follow-up.
• Ensure that specialist psychological support, including psychiatric services, is readily available when necessary.
  

Surgery to the breast and axilla
Surgery is the primary treatment for DCIS and early invasive breast cancer, preferably with breast conservation when possible.

• When no evidence exists of lymph node involvement by ultrasonography or a negative ultrasound guided biopsy, the axilla should be staged by minimal surgery, preferably sentinel lymph node biopsy, rather than lymph node clearance. Perform sentinel lymph node biopsy using the dual technique with isotope and blue dye. Breast units should audit their axillary recurrence rates.
• Further axillary treatment, preferably by lymph node dissection as it gives additional staging information, is required if macrometastases or micrometastases are present in the sentinel lymph node or if there is histologically proved cancer in the preoperative ultrasound guided needle biopsy. Patients with isolated tumour cells in the sentinel nodes should have no further axillary surgery as they are regarded as lymph node negative.
• Discuss immediate breast reconstruction with all patients for whom mastectomy is advised, unless they have significant comorbidity or where adjuvant therapy may be compromised, and discuss the full choice of the different types of breast reconstruction, whether available locally or not.

Planning adjuvant treatment

• Measure the oestrogen receptor status of all invasive cancers using immunohistochemistry and report this quantitatively. The routine measurement of the progesterone receptor status is not needed. Assess the human epidermal growth factor receptor 2 status by using a standardised and qualitatively assured method. Ensure these results are available and recorded at the multidisciplinary team meeting to guide adjuvant treatment decisions.
• Consider adjuvant therapy at the multidisciplinary meeting for all patients with invasive breast cancer after surgery, taking into account the prognostic and predictive factors, the potential benefits and side effects, and the outcome of discussions with the patient.
• Start chemotherapy or radiotherapy as soon as possible within 31 days of completion of surgery.

Endocrine therapy in invasive disease

• For postmenopausal patients with oestrogen receptor positive invasive breast cancer that is not considered to be low risk, offer an aromatase inhibitor, either anastrozole or letrozole, as initial adjuvant therapy. If tamoxifen was chosen as the primary adjuvant treatment an aromatase inhibitor, either exemestane or anastrozole, can be offered after two to three years of tamoxifen, or letrozole after five years of tamoxifen in higher risk patients. When aromatase inhibitors are poorly tolerated or contraindicated as the primary adjuvant treatment, tamoxifen should be given.  

Trastuzumab therapy

• After surgery, chemotherapy and radiotherapy (when applicable) in patients who have breast cancer that is positive for human epidermal growth factor receptor 2 and who have satisfactory cardiac function, offer trastuzumab every three weeks for one year or until disease progression. Trastuzumab is a humanised monoclonal antibody that targets the human epidermal growth factor receptor 2, which is overexpressed in about 15% of breast cancers. Periodic follow-up of cardiac function during the year is mandatory.

 Managing bone health

• Offer baseline dual energy x ray absorptiometry to assess bone mineral density in patients starting aromatase inhibitor treatment, those who have had treatment induced menopause, or those having ovarian ablation or suppression, as all these treatments can cause considerable bone loss and consequent risk of fracture.
• Offer bisphosphonates to patients according to UK consensus guidance for managing breast cancer treatment induced bone loss.

Adjuvant radiotherapy

• Recommend breast radiotherapy after breast conservation surgery in patients with invasive disease, and consider it after surgery for DCIS.
• After mastectomy, discuss chest wall radiotherapy in higher risk patients, mainly depending on lymph node involvement.
• A dose of 40 Gy in 15 fractions using external beam radiotherapy is recommended.
• Do not irradiate the nodal areas routinely.

 Primary systemic therapy

• Endocrine therapy alone rather than primary surgery is not appropriate unless surgery is contraindicated.
• After preoperative chemotherapy for locally advanced or inflammatory breast cancer, offer mastectomy followed by radiotherapy. It would be exceptional to perform breast conservation.

 Complications of local treatment and menopausal symptoms

• Provide patients with information before surgery or radiotherapy on the risk of lymphoedema and factors such as infection that may cause or exacerbate it, including postoperative physiotherapy regimens. If lymphoedema develops ensure rapid access to a lymphoedema service.
• Discontinue hormone replacement therapy in all patients diagnosed with invasive breast cancer, and do not offer it routinely to women with menopausal symptoms who have a previous history of the disease. Offer support, written information, and counselling for those women who might develop menopausal symptoms as a result of their treatment

Follow-up

• After treatment for invasive cancer and DCIS, offer annual mammography for five years to all patients.
• Discuss clinical follow-up (which can be in primary, secondary, or shared care) with the patient. Provide an agreed written care plan including details of the designated named healthcare professionals, dates for review of any adjuvant therapy and surveillance mammography, and other contacts such as the lymphoedema service.

You can read the report in full here.