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Mount Vernon Cancer Network
Breast NSSG
Guidelines for Management of Breast
Cancer
11-1C-103b
Version number as approved and published
Author
Date Written
Date Reviewed
Review Date
NSSG Ratified
0.5
Mr Ravichandran / Dr A Makris
May 2009
February 2013 (Sarcoma pathway
added)
August 2014
12th September 2011
Agreed by:
Position:
Name:
Organization:
Date agreed:
Chair of Network Board
Dr Jane Halpin
NHS Hertfordshire
29th September 2011
Position:
Name:
Organization:
Date agreed:
Breast NSSG Chair
Mr D Ravichandran
Luton & Dunstable Hospital NHS FT
12th September 2011
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Introduction
Referral Guidelines
2.1 Referrals from Primary Care to Secondary Care MDT
2.2 General Recommendations
2.3 Specific Recommendations
2.4 Investigations
2.5 Referrals from Secondary Care MDT to Secondary or
Tertiary Care MDT
Diagnosis and Imaging
Management of Early Disease
4.1 Breast Surgery
4.2 Indications for Mastectomy
4.3 Management of Axilla
Radiotherapy
5.1 Breast
5.2 Post Mastectomy
5.3 Nodal Irradiation
5.4 Timing of Radiotherapy
5.5 Patient Position
5.6 Whole Breast (after tumour excision)
5.7 Breast Boost
5.8 Chest Wall (after mastectomy)
5.9 Lymph Nodes
5.10 Dose Prescriptions
5.11 Radiotherapy for DCIS
Adjuvant Systematic Therapy
6.1 Premenopausal
6.2 Postmenopausal
6.3 Adjuvant Endocrine Therapy
6.4 Chemotherapy Schedules
6.5 Adjuvant Herceptin
Management of Metastatic Disease
7.1 Hormonal Therapy
7.2 Faslodex
7.3 Chemotherapy
7.4 Herceptin
Bisphosphonates
8.1 Bone Metastases
8.2 Brain Metastases
8.3 Spinal Cord Compression
MVCN Guidance on Screening and Symptomatic Breast
Imaging
9.1 Introduction
9.2 Guidance Evidence
9.3 Summary of Guidelines
9.4 Organisation of Breast Imaging Services
9.5 Imaging of Women with Breast Implants
9.6 Image-guided Breast Interventional Procedures
9.7 Supplementary Imaging Techniques
9.8 Professional Standards
9.9 Equipment
9.10 Appendix – Breast Radiologist Professional Standards
Follow-up
10.1 MVCN NSSG Follow Up Guidelines
PAGE
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11.
12.
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10.2 NICE Guidance on Follow Up
10.3 Clinical Evidence
10.4 Health Economic Evaluation
10.5 Recommendations
10.6 Qualifying Statement
Management of Locally Advanced Breast Cancer
11.1 Guidelines for the use of Neoadjuvant Chemotherapy
11.2 Primary Neoadjuvant Endocrine Therapy
Familial Breast Cancer
Hypercalcaemia
Breast cancer patient information pathways
14.1 Prevention and Risk Factors
14.2 Symptom Awareness and Early Detection
14.3 Screening
14.4 Referral, Tests and Investigation
14.5 Diagnosis and Staying
14.6 Treatments
14.7 Follow up Care and Cancer in Remission
14.8 Advanced Cancer and Recurrence
14.9 All Stages
Appendices
Appendix 1
TNM Staging
Appendix 2
Chemotherapy Schedules
Appendix 3
Oncological Emergencies
Appendix 4
Calculation of Dose in the Axilla
Appendix 5
MVH Breast Presentation Sheet
Appendix 6
Effects of Adjuvant Tamoxifen and Chemotherapy
Appendix 7
Use of Taxanes for Breast Cancer
Appendix 8
Use of Vinorelbine for the Treatment of Advanced Breast Cancer
Appendix 9
Use of Herceptin
Appendix 10
Use of Capecitabine for the Treatment of Locally Advanced or
Metastatic Breast Cancer
Appendix 11
Use of Hormone Antagonists
Appendix 12
Royal Marsden Guidelines for AI and post treatment
amenorrhoea
Appendix 13
Recommendations for Vaccinations in Patients Undergoing
Chemotherapy
Appendix 14
Breast Radiotherapy Competency Proforma
Appendix 15
Guidelines for the Handling and Pathological Reporting of Breast
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1.
Cancer Specimens, MVCN Breast NSSG 01-1C-106b
Appendix 16
Sarcoma Pathway
Introduction
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The Mount Vernon Breast Cancer Network has generally decided to adopt “Surgical
Guidelines for the Management of Breast Cancer, Association of Breast Surgery at
BASO, 2009 (sections 4-10) available at http://www.baso.org.uk/Downloads /YEJSO
_2782.pdf and published by EJSO in April 2009 and “Quality assurance guidelines for
surgeons in breast cancer screening, NHSBSP publication No 20, March 2009”
(http://www.baso.org.uk/Downloads/NHS-BSP-20-4e-final.pdf). NICE guidance on Early
and locally advanced breast cancer: diagnosis and treatment and Advanced breast
cancer: diagnosis and treatment, February 2009 has also been considered in the
formulation of these guidelines.
Following is a summary of diagnostic and treatment guidelines derived from the above
and in some instances slightly modified for the network.
4
2.
Referral Guidelines
2.1 Referrals from Primary Care to Secondary Care MDT
(based on NICE Clinical Guidelines CG 027 available at
http://www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf.)
2.2 General recommendations
A patient who presents with symptoms suggestive of breast cancer should be referred to
a team specialising in the management of breast cancer. It should be noted that new
national cancer plan target to see all breast referrals in secondary care within 2 weeks of
referral being received became live on 1 January 2010. It is anticipated that all MDT’s
within MVCN would be able to meet this target. However, if the general practitioner
suspects cancer, the patient should still be referred urgently as “2-week cancer wait”
referral and the MVCN form embedded below could be used.
Agreed Breast 2WW
proforma.doc
In most cases, the definitive diagnosis will not be known at the time of referral, and many
patients who are referred will be found not to have cancer. However, primary healthcare
professionals should convey optimism about the effectiveness of treatment and survival
because a patient being referred with a breast lump will be naturally concerned.
People of all ages who suspect they have breast cancer may have particular information
and support needs. The primary healthcare professional should discuss these needs
with the patient and respond sensitively to them.
Primary healthcare professionals should encourage all patients, including women over
50 years old, to be breast aware1 in order to minimise delay in the presentation of
symptoms.
2.3 Specific recommendations
A woman’s first suspicion that she may have breast cancer is often when she finds a
lump in her breast. The primary healthcare professional should examine the lump with
the patient’s consent. The features of a lump that should make the primary healthcare
professional strongly suspect cancer are a discrete, hard lump with fixation, with or
without skin tethering. In patients presenting in this way an urgent referral should be
made, irrespective of age.
In a woman aged 30 years and older with a discrete lump that persists after her next
period, or presents after menopause, an urgent referral should be made.
Breast cancer in women aged younger than 25 years is rare, but does occur. Benign
lumps (for example, fibroadenoma) are common, however, and a policy of referring
1
Breast awareness means the woman knows what her breasts look and feel like normally. Evidence
suggests that there is no need to follow a specific or detailed routine such as breast self examination, but
women should be aware of any changes in their breasts (see
http://cancerscreening.org.uk/breastscreen/breastawareness for further information).
5
these women urgently would not be appropriate; instead, non-urgent referral should be
considered. However, in women aged younger than 30 years:



with a lump that enlarges, or
with a lump that has other features associated with cancer (fixed and hard), or
in whom there are other reasons for concern such as family history2 an urgent
referral should be made.
The patient’s history should always be taken into account. For example, it may be
appropriate, in discussion with a specialist, to agree referral within a few days in patients
reporting a lump or other symptom that has been present for several months.
In a patient who has previously had histologically confirmed breast cancer, who presents
with a further lump or suspicious symptoms, an urgent referral should be made,
irrespective of age.
In patients presenting with unilateral eczematous skin or nipple change that does not
respond to topical treatment, or with nipple distortion of recent onset, an urgent referral
should be made.
In patients presenting with spontaneous unilateral bloody nipple discharge, an urgent
referral should be made.
Breast cancer in men is rare and is particularly rare in men under 40 years of age.
However, in a man aged 40 years and older with a unilateral, firm subareolar mass with
or without nipple distortion or associated skin changes, an urgent referral should be
made.
2.4 Investigations
In patients presenting with symptoms and/or signs suggestive of breast cancer,
investigation prior to referral is not recommended.
In patients presenting solely with breast pain, with no palpable abnormality, there is no
evidence to support the use of mammography as a discriminatory investigation for
breast cancer. Therefore, its use in this group of patients is not recommended. Nonurgent referral may be considered in the event of failure of initial treatment and/or
unexplained persistent symptoms.
2.5 Referrals from secondary care MDT to secondary or tertiary care MDT
1. Referrals are made to other MDTs within the Trust and outside the Trust according
the symptomatic indications in the above guidelines and/or the results of current
investigations, and should be first discussed at the local breast MDM.
2. Internal MDT to MDT referrals are made by fax to the relevant MDT coordinator
and consultant, to include a referral letter and any relevant investigation results.
Patient notes and radiology packet should be forwarded as soon as possible by
the MDT coordinator.
3. For referrals outside the Trust, a referral letter by an MDT consultant should be
done and preferably faxed and also posted. Copies of relevant clinic letters,
2
National Institute for Clinical Excellence (2004) Familial breast cancer: the classification and
care of women at risk of familial breast cancer in primary, secondary and tertiary care. NICE
Clinical Guideline No. 14. London: National Institute for Clinical Excellence. Available from:
www.nice.org.uk/CG014
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imaging results and pathology results should accompany the original referral letter
to avoid any delay in patient management at the receiving centre. Actual images
(such as mammograms, US, CT, bone scan and MRI) should be sent where
relevant in film or CD format. Pathology tissue blocks may also be sent on
request.
2.6 When the MDT diagnosis is Soft Tissue Sarcoma
As defined in the NICE Improving Outcomes Guidance for the management of Sarcoma
(2008) all Sarcomas are to be discussed at a designated Sarcoma centre. MVCN does
not host a Sarcoma centre, nor does it have a designated clinic operating in any of the 3
acute trust hospitals. All patients must be referred to the Sarcoma (supranetwork)
multidisciplinary team for discussion at the earliest suspicion of Sarcoma, or when
histology identifies an unexpected Sarcoma. The MVCN designated centre is the
London and South East Sarcoma Network, which is hosted by the Royal National
Orthapedic Hospital, for bone Sarcomas and UCLH for soft tissue Sarcomas.
The UCLH MDT is held on Fridays at 08.00, and is a joint MDT, videoconferenced with
the RNOH bone and soft tissue Sarcoma MDT.
The contact details are: MDT Coordinator
Maria Jose, [email protected], telephone- 0207 691 2303 ext 4821, Fax- 020
3447 9536.
UCLH Sarcoma MDT Lead Clinician: Dr Jeremy Whelan; [email protected]
Telephone 0207 380 9346.
Please note: cut off for referrals is the Wednesday preceding the Friday meeting.
The Sarcoma MDT will review all cases of Breast Sarcoma. It is anticipated that surgery
will be undertaken by local Breast services after discussion with the Sarcoma MDT.
Management will be undertaken in accordance with guidelines agreed across the two
Sarcoma MDTS.
2.7 When the cancer is diagnosed in a Child or Young Person
Children with Breast cancer (up to 16 years) must be referred to one of the two network
agreed primary treatment centres (GOSH or Addenbrookes).
Young people with Breast Cancer (16-24) will be referred to the network agreed Young
Persons’ MDT at UCLH for discussion. Place of treatment for this group will depend
upon their age. All 16, 17 and 18 year olds must be treated at the Young Persons’ PTC.
19-24 year olds will be discussed at MDT and then will have the choice whether to be
treated at the PTC or at their local shared care designated hospital.
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Diagnosis and Imaging (please see detailed imaging guidelines)
All patients with breast cancer should undergo bilateral mammography Ultrasound
should be performed in all cases except when its value is limited such as in very large
tumours, ulcerated tumours, inflammatory carcinoma, DCIS. Diagnosis should be
confirmed by core biopsy, done preferably under US or stereotactic guidance. In rare
cases where a core biopsy may not be feasible FNAC confirmation is acceptable.
Axillary ultrasound should be performed in cases of invasive carcinoma and preferably
also in high grade DCIS with guided FNAC / core biopsy of the node(s) if suspicious
nodes are found.
Pre-operative assessment by MRI is useful in selected cases – this should be done
according to local protocol / MDT decision. Suitable cases include;
1.
2.
3.
4.
a core biopsy diagnosis of invasive lobular carcinoma
suspicion of multifocal / multicentric disease
extent of disease unclear on conventional imaging (such as in dense breasts)
discrepancy between the clinical and radiological estimation of extent of disease
especially where breast conserving surgery is planned
5. suspicion of recurrence in a previously treated breast
6. patients presenting with positive axillary nodes with no demonstrable primary on
conventional imaging.
7. Patients with breast impants
Routine pre-operative staging investigations may be done according to the local
protocol but extensive / unnecessary investigations should be avoided. CT chest,
abdomen and pelvis +/- isotope bone scan are appropriate in patients with >4 nodes +ve
and/or T3/T4 tumours.
Recurrent Disease: confirmation by FNAC or Core biopsy with re-staging (Bloods, CT
and Bone Scan)
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4.
Management of Early Disease
4.1 Breast Surgery
A full thickness wide local excision (WLE) should be the standard operation for the
breast primary (invasive or DCIS).
Impalpable or difficult to feel tumours should undergo preoperative localisation.
Intraoperative specimen radiography is mandatory in these cases. These should be
reported by the surgeon and / or the radiologist and result documented in the notes.
An oncoplastic approach should be adopted whenever practicable to reduce the
cosmetic deformity.
Each unit should have its own protocol regarding radial margins. Generally a minimum
of 2mm margin is acceptable (NICE guidelines 2009) Involved radial margin(s) should
be re-excised.
4.2 Indications for mastectomy
1.
2.
3.
4.
5.
Patient choice
Unable to give radiotherapy (e.g., previous radiation to breast area)
Multifocality (some may be suitable for BCS)
Extensive (>40 mm) DCIS
Large (relative to the size of the breast) or centrally placed tumours where a WLE
may result in a cosmetically unacceptable result
6. Failure to clear tumour by previous WLE(s)
All suitable patients requiring mastectomy should be offered the option of immediate
reconstruction of breast.
The local recurrence rate after BCS at 5 years should be less than 5% for invasive
carcinoma and <10% for DCIS.
4.3 Management of Axilla
Unless there is a valid documented reason (discussed in the MDT), all patients with
invasive carcinoma require axillary staging.
Axilla should also preferably be staged in the following cases of DCIS; high grade DCIS
(except very small, <10 mm), extensive (> 40 mm) DCIS, palpable DCIS, known
microinvasion, DCIS requiring mastectomy.
Those with clinically malignant nodes in the axilla and those with positive axillary FNAC
should undergo axillary clearance (Level II at least).
Other patients should preferably be staged with sentinel node biopsy (or by axillary
nodal sampling / low clearance in occasional cases).
Some patients with clinically and US negative axilla may need to undergo axillary
clearance e.g, medically or psychologically unfit patients and elderly in whom a recall for
clearance after a positive SLNB is not appropriate but this should be infrequent. The
level of clearance should be discussed and agreed in the MDT.
A positive SLNB or axillary sampling should be treated with an axillary clearance (level II
at least), or axillary radiotherapy.
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SLNB biopsy should be done using both dye and isotope as this approach appears to
result in higher identification rates and least number of false negative nodes.
Intra-operative testing of SLN should be practised wherever possible to reduce the
recall rate.
SLN micrometastases should be discussed in the MDT and a clearance offered if
appropriate.
No further axillary procedure is necessary for isolated tumour cells detected in the SLN
(or axillary sampling).
Patients considered for neoadjuvant chemotherapy or breast reconstruction may
undergo SLNB prior to these procedures. SLNB after neoadjuvant chemotherapy could
be considered in patients with clinically / radiologically negative axillae at diagnosis.
The axillary recurrence rate after any form of axillary surgery and / or radiotherapy
should be less than 5% at 5 years.
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5.
Radiotherapy
5.1 Breast
Radiotherapy should be routinely offered to patients after wide local excision as this will
reduce the risk against local recurrence.
5.2 Post Mastectomy
Radiotherapy is recommended for patients with large tumours (>4cm, involved axillary
nodes, close (or involved) excision margins (<5mm). Additionally radiotherapy should be
considered for patients with multifocal disease, grade 3 histology and lymphovascular
invasion.
5.3 Nodal Irradiation
Axilla
Level 1 axillary dissection / axillary sampling or sentinel node biopsy: if positive
recommend further surgery or radiotherapy.
Level 2 or 3 axillary dissection: nodal irradiation is not routinely offered, but may be
considered in patients with extranodal disease in the axilla.
Supraclavicular fossa
Recommend in patients with apical and/or > 4 lymph nodes positive disease, additionally
considering patients with < 4 nodes if < 10 nodes have been removed or after
neoadjuvant chemotherapy.
5.4 Timing of Radiotherapy
For patients who are receiving anthracyclines +/- taxanes, radiotherapy should always
be at the end of the chemotherapy. For patients receiving CMF radiotherapy can either
be given at the end of chemotherapy or concurrently.
If chemotherapy is given concurrently, radiotherapy should be omitted on the day of the
chemotherapy.
5.5 Patient Position
The patient must lie supine and the position must remain unchanged during planning,
simulation and treatment. If tangential and nodal fields are given, the patient must not
be moved between fields.
5.6 Whole Breast (after tumour excision)
Clinical Target Volume
Soft tissues of the whole breast down to the deep fascia but not including underlying
muscle and rib cage, nor overlying skin and excision scar.
Planning Target Volume
Medial and lateral borders should not normally extend beyond the anterior mid-line or
the mid-axilla. It is desirable to reduce these margins in selected patients if the tumour
bed does not encroach in order to reduce the volume of heart and/or lung in the high
dose zone. Irradiation of the rib cage below the infra-mammary fold is unnecessary
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unless the tumour bed encroaches on this margin or the lower border of the breast
overlaps the infra-mammary fold.
Deep margin extends down to the deep fascia but the treatment volume inevitably
includes the pectoralis major and rib cage.
The maximum thickness of lung included in the tangential fields should be 2.0cm defined
by CT (rarely 3.0cm may be accepted). Alternative verification of lung depth by
simulator or machine films is acceptable. CT planning is now routine within the
department.
If lymphatic fields are used, divergence of the superior border of the tangential field
should be eliminated if possible by the use of asymmetric diaphragms.
Dose Reference Point
Doses should be prescribed to the reference point defined as the point halfway between
the lung surface and the skin surface on the perpendicular bisector of the posterior beam
edge. This has been termed the "START" reference point.
5.7 Breast Boost
A breast boost is recommended in the following patients:
Patients under the age of 60
Patients over the age of 60 with a resection margin of <5mm
Clinical Target Volume
The tumour bed is an imprecise concept described as being the residual tissue in the
vicinity of the resected tumour. Information should be obtained from the pre-operative
notes and mammography.
Planning Target Volume
Includes the tumour bed with lateral margins of 2cm and the deep margin extending to
the underlying muscle fascia. The planning target volume is typically 7cm-9cm in
diameter at the skin's surface (i.e. 8cm diameter electron applicator).
Field Arrangement
Electrons for appropriate energy (8-18 MeV) are recommended but other techniques
using a planned volume or small opposing tangential x-ray beams may be acceptable
particularly in patients with large breasts. Electrons usually involve a direct electron field
without bolus. A circle or alternative shape of 8-10cm is usually needed.
Reference Point
The dose is prescribed to the 100% isodose for electrons.
5.8 Chest Wall (after mastectomy)
Radiotherapy should be considered for patients at high risk of local recurrence. Patients
with ≥ 4 axillary lymph nodes should be offered chest wall radiotherapy. Those with 1-3
nodes positive should be considered for the SUPREMO trial. Outside the trial the
decision to offer radiotherapy or not is taken after discussion of risks/benefits with the
patient. Patients with involved or close (≤ 1mm) deep margin should be offered
radiotherapy. Other risk factors including tumour size, grade III, and lymphovascular
invasion should be considered in the decision to offer radiotherapy but in isolation are
not sufficient to offer radiotherapy (except for very large tumour size).
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Clinical Target Volume
Skin flaps but not underlying muscle and rib cage.
Planning Target Volume
Anteriorly to include the skin flaps and build up may be needed according to beam
energy. Posteriorly the deep margin extends to the deep fascia but the treatment
volume inevitably includes underlying muscles and the rib cage. Medially and/or laterally
the surgical scar may need to be left out in order to reduce exposure of underlying heart
and/or lung.
Efforts should be made to minimise exposure to the heart.
The field arrangements are as for the whole breast.
5.9 Lymph Nodes
Clinical Target Volume
Axillary Chain +/- Supraclavicular Nodes.
Planning Target Volume
Supraclavicular fossa: Superiorly the planning target volume extends at least 3cm above
the medial end of the clavicle. Medially it extends to the sterno-clavicular joint. If no
axillary radiotherapy is given, the inferior border is at the lower border of the clavicle and
the lateral border is at the junction of the medial two-thirds and lateral one-third of the
clavicle. If the axilla is included the supraclavicular fossa volume shares the same
inferior and lateral borders of the axilla.
Axilla: Inferiorly the border matches the junction with the tangential fields, correcting for
divergence in both planes. Superiorly the field border extends to the lower border of the
clavicle. Medially the volume includes the rib cage, plus 1cm-2cm lung on simulator or
check film. Laterally it extends to the outer border of the head of the humerus; this
border should be confirmed by inspection and may need to be moved laterally in obese
patients but only to include the axillary nodes by palpation and not excess soft tissue
beyond the chest wall.
Field Arrangements
A single anterior field encompassing the planning target volume is recommended. An
applied posterior axillary field treated daily is suggested when the mid-axilla dose falls
below 80%-85%.
Localisation of the target volume and field size/shape is determined using a simulator.
Note that the apex of the axillary node chain corresponds, at simulation, to where the
inferior border of the clavicle intersects the 1st rib. Lead shielding should be applied to
the head of humerus and lung apex on anterior and posterior portals as appropriate.
Matching of the inferior border to the superior border of tangential fields should
preferably be achieved using asymmetrical diaphragms.
The antero-posterior thickness of the axilla should be recorded at the anterior field
centre in all patients, whichever field arrangement is used.
5.10 Dose Prescriptions
Breast or Chest Wall
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40Gy to the "START" reference point in 15 fractions over 3 weeks or 50Gy to "START"
reference point in 25 fractions over 5 weeks to patients with large breasts.
For patients who have had mastectomy and implant insertion a dose of 50Gy in 25
fractions over 5 weeks may be used.
Breast Boost
10.5Gy in 3 fractions over 3 days to the 100% isodose.
Axilla or supraclavicular fossa
Supraclavicular fossa only
40Gy in 15 fractions over 3 weeks applied dose
Axilla +/- SCF
50Gy in 25 fractions over 5 weeks. If the mid-axilla dose falls below 80%-85%,
consider a daily applied posterior axilla field as per START protocol.
Appendix III – calculation of dose in the axilla.
5.11 Radiotherapy for DCIS
After mastectomy radiotherapy is not routinely offered unless margins are involved.
After wide local excision radiotherapy is usually offered. Radiotherapy schedule and
technique are as for invasive cancer. At present there is no evidence for benefit of a
boost to the tumour bed during radiotherapy but this may be considered on an individual
basis in the presence of close margins (≤ 2mm) where re-excision has not been
attempted.
For patients with a small (<1cm) low or intermediate grade discrete screen detected
areas of DCIS radiotherapy may be avoided. Patients could be offered observation with
regular screening mammograms.
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6.
Adjuvant Systemic Therapy
For both pre- and post-menopausal women consideration of chemotherapy should take
into account the risk of relapse and death and the possible benefits of chemotherapy, as
can be obtained using the adjuvant on-line programme.
6.1 Premenopausal
Chemotherapy should be considered for all patients with tumours 1 cm.
Tamoxifen should be recommended for all patients with ER and/or PgR +ve tumours.
Ovarian ablation to be considered for high risk ER and/or PgR +ve patients who have
not become menopausal after chemotherapy + tamoxifen, and who are under the age of
40.
Tamoxifen + ovarian ablation is an option for women with ER and/or PgR +ve cancers
who do not want to have chemotherapy.
The impact on fertility and menopausal symptoms must always be discussed with the
patient.
6.2 Postmenopausal
Tamoxifen or aromatase inhibitors should be recommended to patients with ER and/or
PgR +ve tumours.
Chemotherapy should be considered for patients with tumours 1 cm.
Chemotherapy is generally recommended for patients with positive axillary lymph nodes.
The absolute benefit of adjuvant chemotherapy in ER/PgR +ve tumours is small and the
decision to use chemotherapy should be taken after careful discussion with the patient.
There is currently no data to support the use of adjuvant chemotherapy in patients over
the age of 70. However chemotherapy could be considered for high-risk patients
over the age of 70 after the benefits and side effects have been discussed with the
patient.
Tamoxifen or aromatase inhibitors to be recommended for five years.
Tamoxifen or aromatase inhibitors should be given after completion of chemotherapy.
6.3 Adjuvant Endocrine Therapy
Refer to MVCC guidelines for the use of Aromatase Inhibitors (AIs) and Tamoxifen in the
adjuvant treatment of early breast cancer. For high-risk patients: axillary node positive
and/or grade III, five years of anastrozole or letrozole is recommended. For low-risk
patients: axillary node negative, tumour site < 2cm, grade I or II, five years of tamoxifen
is recommended. For other patients a switch/sequencing of tamoxifen for 2-3 years then
anastrozole or exemestane for 2-3 years (for a total of five years adjuvant therapy) is
recommended.
15
There is an increased risk of osteoporosis with AIs and a bone density scan (DEXA)
should be performed at the start of AI therapy. The risk of osteoporosis needs to be
considered as part of the benefits/risks of adjuvant therapy.
Anastrozole or letrozole should be considered for patients who are intolerant of
tamoxifen or who have a high risk of thromboembolism or endometrial abnormalities, as
per licensed indication.
Post-menopausal women with node positive ER and/or PgR +ve breast cancer who
complete five years of adjuvant tamoxifen should be considered for three years of
adjuvant letrozole.
Women who are pre and peri-menopausal at diagnosis should receive tamoxifen.
(Please see Royal Marsden Hospital guidelines with regards to this, in Appendix XI)
Patients on an AI will require bone surveillance for osteoporosis/osteopenia.
The responsibility lies with the prescribing oncologist/surgeon to discuss the relative
merits of tamoxifen and aromatase inhibitors with each individual patient.
Please refer to Appendix X – Use of AIs within the Mount Vernon Network.
6.4 Chemotherapy schedules endorsed by the Mount Vernon Cancer Centre (see
Appendix I)
1.
2.
3.
4.
FEC x 6
FEC x 3 followed by Taxotere x 3 for high risk node positive
AC x 4
CMF x 6
Recommend FEC, or FEC followed by Taxotere, for high risk patients.
For low risk patients AC x 4 or CMF x 6 are acceptable.
The improvements in outcome of AC x 4 and CMF x 6 are equivalent but toxicity is
different.
6.5 Adjuvant Herceptin
Herceptin is recommended in accordance with NICE guidance. Adjuvant Herceptin
should be considered for patients who are receiving adjuvant chemotherapy and are
HER2 positive. Before embarking on adjuvant Herceptin patients should have cardiac
function determined then monitored every three months throughout treatment by either
echocardiography or MUGA scans. Ejection fraction must be above the lower limit of
normal values of the department in which the scan is performed, before Herceptin can
be commenced. The dose of Herceptin used is a loading dose of 8mg/kg followed by
subsequent treatments every three weeks of 6mg/kg. One year’s adjuvant Herceptin
equates with 18 three-weekly injections.
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7. Management of Metastatic Disease
7.1 Hormonal therapy
First line: Aromatase inhibitors: Anastrozole 1mg daily or Letrozole 2.5mg daily or
Exemestane 25mg daily.
For patients who have failed anastrozole and letrozole, exemestane 25mg daily is an
option. Other options include tamoxifen 20mg daily (if they have not received this
previously in the adjuvant setting), megace (megestrol acetate) 160mg daily. The
optimal sequencing of these agents has as yet not been defined.
Consider ovarian ablation if pre/peri-menopausal. Options:
LHRH analogues
Radiotherapy
Oophorectomy
Hormonal therapy only appropriate for ER + and/or PgR + tumours.
7.2 Faslodex
Faslodex is a new pure antioestrogen with activity similar to AIs in first line metastatic
breast cancer. It is more expensive than AIs and has to be administered by deep im
injection. Members of the MV Breast Cancer Network feel that they should be allowed to
prescribe faslodex for those patients who have failed AIs + Tamoxifen. There is
currently no funding for this.
7.3 Chemotherapy
-
see Appendix VI for NICE guidance on Taxanes
see Appendix VII for NICE guidance on Vinorelbine
see Appendix IX for NICE guidance on Capecitabine
Chemotherapy for metastatic disease is influenced by:
1. Previous adjuvant therapy.
2. Age and performance status of patient.
3. Acceptability of hair loss.
If no previous anthracyclines:
First line:
AC, FEC, MM(M), Epirubicin single agent
Second line:
Taxotere (Docetaxel) 75-100mg/m2 every three weeks
or
Taxol (Paclitaxel) 175mg/m2 every 3 weeks or 60-90mg/m2 every week
or
Capecitabine 1000-1250mg/m2 bd day 1 to day 14 every 3 weeks.
or
Vinorelbine
25-30mg/m2 iv day 1 & day 8 every three weeks is also an
option for patients particularly if there are abnormal LFTs which do not
allow the use of taxanes. (Oral Vinorelbine can be considered as an
alternative to intravenous Vinorelbine.)
The combination of Taxotere 75mg/m2 every three weeks iv and Capecitabine 850mg/m2
bd for 14 days every three weeks could be considered for young fit patients where a
17
higher response rate is desirable. This combination has a greater toxicity than either
agent used alone.
Taxol (Paclitaxel) 175mg/m2 day 1, and Gemcitabine 1250mg/m2 day 1 and day 8 every
three weeks, for high risk patients.
If <2 years since adjuvant anthracyclines:
Taxane or Vinorelbine or Capecitabine (see above).
If >2 years since adjuvant anthracyclines then consider challenging with another
anthracycline schedule.
Gemcitabine 1000mg/m2 day 1 and 8 intravenously and Carboplatin AUC 4-5 day 1 to be
considered for patients who have previously been exposed to anthracyclines, taxanes,
Capecitabine and Vinorelbine.
Review response after 2-3 cycles. If responding or stable disease then continue to 6
cycles if appropriate. For Capecitabine or Vinorelbine consider treatment to 8 cycles if
toxicity is acceptable.
7.4 Herceptin
Use as per NICE guidance (see appendix VIII).
For patients who overexpress HER2 (+++ by immunohistochemistry or +ve by FISH
analysis).
Loading dose of 8mg/kg cycle 1 and 6mg/kg subsequent 3 weekly cycles if no reactions.
Use in combination with Paclitaxel or Docetaxel or Vinorelbine and Capecitabine. The
combination with Vinorelbine is the treatment of choice for patients with deranged LFTs.
Herceptin can be re-started in patients who have received it as adjuvant therapy but who have
relapsed more than six months later.
Refer to guidelines for management of cardiotoxicity.
18
8.
Bisphosphonates
Bisphosphonates should be routinely used for patients with bony metastases to improve
pain control, reduce complications, reduce the need for radiotherapy. Treatment should
be continued while control of the bone metastases is clinically relevant.
In patients without bone metastases bisphosphonate use is not routinely indicated.
Patients with isolated bone metastases can be treated with radiotherapy, and
bisphosphonates delayed until disease progression.
The choice of bisphosphonate is either Pamidronate 90mg iv every three to four weeks
or Zolendronate 4mg iv every three to four weeks. Renal function needs to be monitored
while patients are on intravenous bisphosphonates. For Pamidronate the U&Es from the
previous cycle can be used if renal function has been stable but for Zolendronate U&Es
need to be checked prior to each infusion.
The choice of intravenous bisphosphonate of either Pamidronate or Zolendronate is left
to individual Units. At present Pamidronate is used at the Mount Vernon Cancer Centre
but some Units have chosen to use Zolendronate as this is a shorter infusion and some
evidence suggests it may be more effective.
Although the Mount Vernon Cancer Network members endorse the use of oral
Ibandronate it has not been accepted by the Mount Vernon Network New Drugs Group.
The oral bisphosphonate Clodronate could be considered for use in some patients but
the evidence for its effectiveness is weaker than with the intravenous bisphosphonates.
After six to twelve months of treatment with bisphosphonates if the patient’s disease is
stable breaks in the treatment could be considered.
8.1 Bone metastases
Standard therapy for bone pain is 8Gy single fraction. Consider 20Gy in 5 fractions for
large area, prescribed to cord depth (4 cm dorsal spine, 5 cm lumbar spine).
If cortex is eroded (> 50%) on a major weight bearing bone, consider referral for
orthopaedic assessment.
8.2 Brain metastases
Radiotherapy to the whole brain to a dose of 12Gy in two fractions or 20Gy in five
fractions with Dexamethasone 4 mg qds during radiotherapy.
8.3 Spinal cord compression
Use MRI scan to define the level of compression. A dose of 20Gy in five fractions,
prescribed to cord depth (4 cm dorsal spine, 5 cm lumbar spine).
I complete paralysis for more than 24 hours treat only for pain with single 8Gy fraction.
At weekends consider clinical marking with MRI on Monday.
Dexamethasone 4mg QDS.
19
9.
MVCN Guidance on Screening and Symptomatic Breast Imaging
2010 11-1C-105b
9.1 Introduction
Guidance on the provision and quality of services for imaging in breast cancer screening
are already established through the quality assurance structure integral to the NHSBSP.
However, there is a need to ensure that breast imaging services for patients with
symptomatic breast problems are provided appropriately and to the same high quality
standards as apply in the NHSBSP.
The report to the Chief Medical Officers of England and Wales A Policy Framework for
Commissioning Cancer Services: Guidance for Purchasers and Providers of Cancer
Services identifies the need for multidisciplinary teams for cancer diagnosis and care
(Calman-Hine Report). This report emphasises the importance of a patient-centred and
holistic approach to breast care from referral through diagnosis and assessment to
treatment and palliative care. Implementation of the Calman-Hine recommendations
involves the establishment of specialist breast cancer units linked to Cancer Centres;
breast cancer units are required to treat a minimum of 100 new cases of breast cancer
per annum (EL(96)15).
Key themes in the strategy are:
 development of multidisciplinary teams, including those who provide
imaging services;
 adherence to agreed diagnostic and treatment protocols;
 development of local guidelines on referral practice;
 carrying out clinical audit;
 participation in continuing medical education (CME).
This guidance takes into account the recommendations for symptomatic breast services
published by the Breast Surgeons Group of the British Association of Surgical Oncology
and the British Breast Group and also complements the Quality Assurance Guidelines
for Radiologists in Breast Cancer Screening published by the NHSBSP and endorsed by
the RCR. Comprehensive evidence-based guidance for purchasers on the provision of
breast cancer services has been published by the NHS Executive in Guidance for
Purchasers: Improving Outcomes in Breast Cancer.
With this background, the purpose of Guidance on Screening and Symptomatic Breast
Imaging is to provide a framework on which radiologists and breast teams can base the
provision of breast imaging services.
9.2 Guidance evidence
The guidance uses a three-point grading system to identify the quality of the published
evidence on which the guidelines are based. The grading system is similar to that used
in the Guidance for Purchasers: Improving Outcomes in Breast Cancer - The Research
Evidence which in itself has been adapted from the Clinical Outcomes Group categories
of evidence for use in the writing of clinical practice guidelines.
The grading systems for the recommendations:
Grade A - Based on evidence obtained from at least one randomised controlled trial or
meta-analysis of relevant randomised controlled trials.
20
Grade B -Based on evidence obtained from at least one prospective study with a
comparison group (non-randomised controlled trial or good observation study) and/or
well-designed retrospective/cross-sectional studies.
Grade C - Based on evidence from reports of expert committees, the opinions of
professional bodies and/or clinical experiences of respected authorities. Although there
is lack of direct clinical studies, Grade C recommendation is based on what is regarded
as good clinical practice at the present time.
9.3 Summary of Guidelines
Guidelines
Grade of
recommendation
Patients with symptomatic breast disease who have conditions that
require referral, who may or may not require imaging, should be
referred to a multidisciplinary Specialist Breast Clinic.
C
Imaging of symptomatic disease, which requires specialist referral,
should only be performed as a part of triple assessment (clinical
examination, imaging and needle biopsy [fine needle or core
biopsy]).
B
Mammography is the initial imaging modality of choice in
symptomatic patients over 35 years of age.
B
Ultrasound is the imaging modality of choice in symptomatic
patients under 35 years of age. Mammography is NOT
recommended unless there is a high clinical or ultrasound suspicion
of breast cancer.
B
Asymptomatic women of 50 years of age or over should participate
in the NHSBSP.
A
Asymptomatic women under 50 years of age at high risk of
developing breast cancers (e.g. with a strong family history) should
have their risks determined in a Specialist Breast Clinic before
either annual or biennial mammographic screening is performed
following agreed protocols.
C
Asymptomatic women under 50 years of age receiving hormone
replacement therapy (HRT) for more than five years have only a
small increased risk of breast cancer and routine mammographic
screening is not recommended for this reason alone.
B
Base-line mammography prior to commencing HRT is not
recommended.
C
Radiologists involved in breast imaging (both NHS screening and
symptomatic) should have agreed professional standards and
training.
C
Equipment used in breast imaging should satisfy the technical and
quality requirements laid down by the NHSBSP.
C
21
9.4 Organisation of Breast Imaging Services
9.4.1 Symptomatic breast imaging services
Diagnosis of breast disease should occur in a multidisciplinary setting using the
principles of triple assessment (clinical assessment, imaging and needle
cytology/histology). This is best achieved in designated specialist breast clinics in which
both radiologists and surgeons work closely together. Direct access from GPs for breast
imaging alone is not recommended.
These clinics should:
 provide rapid patient access with measures to identify and prioritise those women
with a higher suspicion of malignancy;
 be organised to ensure that, where possible, all necessary diagnostic procedures
are carried out at the initial clinic visit (where this is not achievable imaging
should be performed and reported within five working days);
 where practical, imaging should precede any needle aspiration or biopsy
procedures.
Imaging should be performed only where there is a clear clinical indication to do so.
Inappropriate requests should be monitored and subjected to audit.
9.4.2 Population breast cancer screening of asymptomatic women
Guidance for radiologists on breast cancer screening has been previously published by
the NHSBSP, and the issue of informed consent has been discussed by the General
Medical Council.
General principles






The technical quality of all screening mammography should be to the standards
required by the NHSBSP.
Radiographers performing screening mammography should hold, or be training
for, the College of Radiographers Postgraduate Award in Mammography
Practice.
Screening mammography should be interpreted by radiologists who satisfy the
professional standards required for radiologists involved in the NHSBSP.
Ultrasound is not an effective imaging method for routine screening.
Screening, wherever performed, should always include formally agreed
mechanisms for referral, without delay, of women with screen-detected
abnormalities to a specialist breast team.
The examination should be preceded (or accompanied) by information detailing
the risks, benefits and imperfections of screening mammography.
Mammographic screening of women of 50 years and over
There is unequivocal evidence from randomised controlled trials that population
screening of women between the ages of 50 and 65 years by mammography alone can,
by early detection, reduce mortality from breast cancer. The NHSBSP provides
screening by invitation every three years for women between the ages of 47 and 73
years; women over the age of 73 years are encouraged to participate. Two-view
mammography (mediolateral oblique and craniocaudal projections of each breast) is
required at each attendance.
22
Screening women between the ages of 40 and 47 years
Individual women in this age group who seek or are referred for mammographic
screening should be made fully aware of the risks (the theoretical radiation risks and the
increased rates of false reassurance, false-positive and false-negative results and
benign surgical biopsies compared to screening in older women) as well as the possible
benefits, before being screened. Two-view mammography at each screening visit is
recommended and mammography is unlikely to be of benefit in this age group if
performed less frequently than annually; screening more frequently than every year is
not recommended.
Screening women under the age of 40 years
There is no evidence of any mortality benefit from mammographic screening of women
under the age of 35 years. There are also greater theoretical risks of radiation-induced
breast cancer from the use of diagnostic x-ray mammography in young women. For
these reasons, routine screening of women in this age group in the absence of any
significant breast cancer risk factors is not recommended.
Assessment of screen-detected abnormalities
In the NHSBSP it is routine for all screen-detected abnormalities (symptomatic and
asymptomatic) to be assessed by a multidisciplinary team of breast specialists, and it is
policy that the NHSBSP has the responsibility to carry out all tests required to confirm
definitively the presence or absence of malignancy.
9.4.3 Breast Imaging Protocols
Symptomatic breast imaging
Conventional routine techniques for imaging the breast are x-ray mammography and
ultrasound. Mammography is the most sensitive routine imaging technique for
demonstrating malignant disease in the breast. Breast cancer is uncommon under the
age of 35 years and is rare under the age of 30 years. Mammography is also less
sensitive for breast disease in younger women because, in general, the normal breast is
denser and more difficult to interpret. For these reasons, the recommended protocols for
the use of breast imaging are age-dependent.
Imaging of symptomatic patients aged 35 years or over:



mammography is the imaging technique of first choice. It is recommended that
the standard mammographic examination should normally include a mediolateral
oblique and a craniocaudal projection of each breast. Supplementary projections
may be performed as directed by the supervising radiologist;
breast ultrasound may provide useful additional information and may be used to
complement mammography, as decided by the supervising radiologist.
Ultrasound may be used as the initial imaging technique where clinical
examination suggests the presence of a benign process such as a simple cyst;
mammography may be performed as a matter of routine and in the absence of
significant clinical signs in symptomatic women of 35 years or over who have not
recently attended for screening as part of the NHSBSP. Ultrasound is not
regarded as a suitable technique for routine breast cancer screening.
23
Imaging of symptomatic patients under 35 years:



a sizeable proportion of women attending breast clinics are under 35 years of
age and many do not require imaging as part of their diagnostic assessment.
There is a low incidence of breast cancer in this age group and diagnosis is
normally achieved by clinical assessment, supplemented where necessary by
fine needle aspiration/core needle biopsy and imaging;
ultrasound is the imaging technique of first choice in women under 35 years with
focal breast problems;
however, where malignancy is suspected, mammography with two views
(mediolateral oblique and cranio-caudal projections) of each breast should be
performed.
9.4.5 Mammographic screening of patients at increased risk of breast cancer
At best there is limited evidence that screening women at increased risk of breast cancer
confers benefit.
Family history
With regards to family history, the following is a summary of the NICE Guideline 41,
October 2006 – “Familial breast cancer: the classification and care of women at risk of
familial breast cancer in primary, secondary and tertiary care” which has been adopted
by the network. The full guidelines are available at: http://www.nice.org.uk/CG41
When a woman presents with breast symptoms or has concerns about relatives with
breast cancer, a first- and second-degree family history should be taken in primary care
to assess risk, because this allows appropriate classification and care. Women at or
near population risk of developing breast cancer (that is, a 10-year risk of less than 3%
for women aged 40–49 years and a lifetime risk of less than 17%) are cared for in
primary care.
Women at raised risk of developing breast cancer (that is, a 10-year risk of 3–8% for
women aged 40–49 years or a lifetime risk of 17% or greater but less than 30%) are
generally cared for in secondary care.
Women at high risk of developing breast cancer (that is, a 10-year risk of greater than
8% for women aged 40–49 years or a lifetime risk of 30% or greater) are cared for in
tertiary care. High risk also includes a 20% or greater chance of a faulty BRCA1, BRCA2
or TP53 gene in the family.
Healthcare professionals should respond to women who present with concerns, but
should not, in most instances, actively seek to identify women with a family history of
breast cancer.
Local protocols for the care of women at risk of familial breast cancer and clear referral
mechanisms between primary, secondary and tertiary care should be available.
Care
Access to psychological support and assessment is a key part of care needed for these
women.
24
All women aged 40–49 years satisfying referral criteria to secondary or specialist care
(at raised risk or greater) should be offered annual mammographic surveillance.
Surveillance should only be undertaken after provision of information about its potential
advantages and disadvantages for the early detection of breast cancer, and where
offered, this should be of high quality (equivalent to NHS Breast Screening Programme
standard) and audited.
Women who are known to have a genetic mutation should be offered annual MRI
surveillance if they are:
– BRCA1 and BRCA2 mutation carriers aged 30–49 years
– TP53 mutation carriers aged 20 years or older.
MRI surveillance should be offered annually when indicated:
From 30–39 years:
– to women at a 10-year risk of greater than 8%
From 40–49 years:
– to women at a 10-year risk of greater than 20%, or
– to women at a 10-year risk of greater than 12% where mammography has shown a
dense breast pattern.
Previous benign breast biopsy
In most cases (70%) a history of previous benign breast biopsy carries no increased risk
of subsequent development of breast cancer. However, a past history of biopsy showing
proliferative epithelial changes is associated with an increased risk of breast cancer (four
times the relative risk). This risk is doubled if there is also a family history of breast
cancer in a first-degree relative. There is no evidence that screening of women with
proliferative changes offers any mortality benefit. However, it is accepted practice to
offer screening to women in this risk category; local clinical practice will determine
whether or not screening is offered in these circumstances. Screening should follow the
same guidance as recommended for family history screening.
Mammography in women receiving HRT
"Baseline" mammography is not routinely required prior to commencing HRT. The
majority of women receiving HRT are over the age of 50 years and are offered screening
every three years as part of the NHSBSP as a matter of routine. In this age group, there
is no evidence to support more frequent screening. For women under the age of 50
years routine screening is not recommended.
9.4.6 The use of imaging in the follow-up of patients with breast cancer
Patients who have been treated for breast cancer may develop recurrence of the primary
cancer or distant metastatic disease and are at increased risk of developing a second
primary breast cancer (six times the lifetime risk). The aim is to detect recurrence or a
second primary as early as possible to maximise the likelihood that treatment will
influence prognosis.
9.4.7 Imaging of the treated breast following surgery with breast conservation
Recurrence is likely to show the same mammographic features as the primary lesion, so
although interpretation may be hampered by post-operative scaring and radiation
changes in a combined clinical and imaging follow-up regime, mammography can be
25
expected to detect 30-40% of clinically occult recurrences and these are likely to have
better prognostic features.
9.4.8 Imaging of the opposite breast after treatment for breast cancer
Monitoring the contralateral breast will detect a higher proportion of better prognostic
cancers than clinical examination.
9.4.9 Frequency and duration of follow-up (Please see network follow-up
guidelines)
Clear evidence on the frequency of follow-up mammography is not available, but it is
considered reasonable practice that it should be at least once every two years and no
more frequently than annually. Once an abnormality is detected, either clinically or
radiologically, rapid access is required to special view mammography and ultrasound.
Confirmation requires needle biopsy for histology or cytology. Where conventional triple
assessment has been unhelpful in the investigation of patients with suspected
recurrences, MRI has been shown to be useful.
9.5 Imaging of women with breast implants
Women with a prosthesis who undergo mammography - and the radiographers who
perform their examinations - should be aware that the risk of prosthesis rupture as a
result of compression during mammography is extremely small. The presence of any
visible breast asymmetry should, however, be recorded before mammography is
performed in case the examination is blamed for producing an existing abnormality.
There is no evidence that breast augmentation is associated with an increased incidence
of carcinoma.
9.5.1 Women with breast implants and symptoms
Women should have had a clinical examination by an experienced clinician prior to
imaging. Ultrasound of the area of suspicion is the preferred initial imaging method, and
is particularly valuable for mass lesions. Should mammography be considered
necessary, the displacement techniques described by Eklund are particularly valuable
for calcifications and for parenchymal deformities in women with a small prosthesis
occupying less than 50% of breast volume. In consultation with the clinician, ultrasoundguided fine needle aspiration cytology (FNAC) can often prove extremely valuable. MRI
may provide further useful information regarding the presence of malignancy and implant
rupture.
9.5.2 Breast screening
In the NHSBSP, prostheses are present in fewer than 2 per 1,000 women screened
and, therefore, do not present a significant problem. Screening by mammography is still
considered the most appropriate modality for excluding breast cancer.
If practicable, women should be given appointments to attend a unit where films can be
processed and additional mammographic views can be performed. A longer than usual
appointment time will be required.
The screening examination must be "tailored" to each woman. The most appropriate
mammographic technique is dependent on the volume and position of the implants in the
breasts. The following procedure is suggested:
26






mediolateral oblique views should be performed initially to assess the size
and position of the prostheses;
cranio-caudal views using Eklund displacement technique;
for small prostheses (less than 50% of breast volume) a three view
technique (mediolateral oblique, true lateral and cranio-caudal
projections) will show at least 70% of breast volume if the displacement
technique is used;
for moderate sized prostheses (50-75% of breast volume) each case
should be judged on its own merits;
for large prostheses (more than 75% of breast volume) further x-ray
mammography is not usually indicated;
ultrasound is not recommended for screening but, if used for women with
breast prostheses because mammograms of diagnostic quality are not
obtainable, women must be made aware of the high false-negative results
associated with this technique. All efforts must be made to avoid false
reassurance.
Each woman should be provided with advice about the value of mammographic
screening according to the size of her particular prostheses. "Breast awareness" is an
important back-up technique for this group of women.
9.6 Image-guided breast interventional procedures
Percutaneous sampling of breast lesions is important to avoid unnecessary surgery for
benign problems and provide pre-operative diagnosis of malignant lesions, allowing for
informed patient counselling and treatment planning. The radiologist plays an important
role in obtaining representative tissue, particularly from impalpable lesions. Needle
aspiration and/or biopsy should be performed on all clinically or radiologically
indeterminate, suspicious or malignant breast abnormalities. Radiologists involved in
image-guided sampling of breast lesions are advised to work to written protocols.
9.6.1 FNAC and wide-bore core biopsy (WBCB)
1. FNAC and WBCB are essential components of triple assessment and
radiologists with a special interest in breast imaging should be skilled in these
techniques.
2. To ensure accurate sampling, image guidance may be the preferred technique
for sampling palpable as well as impalpable lesions.
3. Ultrasound guidance is recommended where lesions can be confidently seen
on ultrasound.
4. Stereotaxis is the recommended technique for guiding biopsy of lesions not
clearly visible on ultrasound. For x-ray-guided biopsy, check films must be
performed to confirm that the appropriate area is sampled.
5. FNAC and WBCB should be performed after full clinical assessment.
6. The recommended techniques for FNAC are fully described in the Guidelines
for Non-Operative Diagnostic Procedures and Reporting in Breast Cancer
Screening.
7. For individual radiologists performing image-guided FNAC, an absolute
adequacy rate of more than 70% is required.
27
8. For WBCB, the best results are likely to be achieved if 14-gauge needles are
used with a spring-loaded biopsy device.
9. WBCB is suggested for microcalcifications, and specimen radiography is
required to confirm adequate sampling.
10. Vacuum-assisted biopsy will yield greater amounts of tissue which should
produce greater diagnostic accuracy. However, the equipment is expensive and
its exact role is still being established.
9.6.2 Localisation of impalpable lesions for surgical biopsy and excision
1. Localisation should allow accurate excision of the abnormality in order to
obtain a diagnostic sample weighing less than 20 grams.
2. The technique or techniques used are determined by the type and position of
the lesion being targeted and by the preferences of radiologists and surgeons.
3. Ultrasound guidance is recommended where lesions can be confidently seen
on ultrasound. Skin marking may be preferred for superficial lesions.
4. Wire localisation is recommended for more deep-seated abnormalities; the
wire should pass within 10 mm of the margin of the lesion. It is recommended
that check films should always be performed to confirm accurate localisation; if
not the procedure should be repeated.
5. Following excision, specimen radiography should be performed for all imageguided localisations for impalpable lesions to confirm that adequate excision or
sampling has been achieved. Section radiography will aid histopathological
assessment of these specimens. A dedicated specimen x-ray machine is
preferred.
9.7 Supplementary imaging techniques
9.7.1 MRI
The exact role of breast MRI in the investigation and management of breast cancer has
yet to be fully established. Breast MRI has advantages in high sensitivity for invasive
(but less so for in situ) disease and does not use ionising radiation. It may be useful in
1. evaluating potential recurrence following conservation surgery.
2. excluding multifocal disease prior to breast conserving surgery.
3. evaluation of patients undergoing neoadjuvant chemotherapy.
4. assessing patients with breast implants for implant integrity and the
presence of suspected malignancy.
5. invasive lobular carcinoma (on core biopsy) – to assess extent of disease
and bilaterality.
28
6. radiologically dense breasts and in cases where there is a discrepancy
with regards to disease extent between clinical examination and
conventional imaging.
7. patients presenting with nodal (or rarely other) metastases but no obvious
breast primary on clinical examination and conventional imaging.
The disadvantages of MRI are its expense, limited availability, a wide variation in
reported specificity and the lack of biopsy facilities for lesions detected by MRI alone.
9.7.2 Scintimammography
Breast cancer and nodal metastases can be detected using 99mTc Sestamibi and other
isotopes. Some have advocated scintimammography for problem solving, in dense
breasts, recurrent breast cancer following surgery, for sentinel node biopsy and in
monitoring tumour response to chemotherapy. Insufficient data is, however, available at
the present time for firm guidelines to be issued regarding the role of nuclear medicine in
breast cancer imaging, and particularly how it interrelates with other imaging modalities.
9.8 Professional Standards
9.8.1 Radiologists involved in symptomatic breast imaging
Radiologists with a special interest in symptomatic breast imaging should:
 assume responsibility for the provision and quality of imaging in symptomatic
breast services;
 have undergone appropriate training in accordance with RCR guidelines;
 be personally involved in the interpretation and reporting of a minimum of 500
symptomatic mammograms per annum;
 be part of a multidisciplinary team associated with a designated specialist breast
unit;
 have appropriate contracted time (identified in a personal job plan) specifically
designated for participation in multidisciplinary breast assessment. It is
anticipated that a specialist breast radiologist will require two, and preferably
three, fixed sessions dedicated to breast assessment. This should include
participation in diagnostic breast clinics organised to ensure that direct and timely
consultation with the other members of the clinical team can take place;
 participate in regular (usually at least weekly) multidisciplinary clinical case
management meetings;
 ideally also participate in the NHSBSP;
 possess the skills required to report mammography, perform and interpret breast
ultrasound, supervise specialist mammography techniques and perform imageguided biopsy and localisation of impalpable breast lesions. Mammography and
breast ultrasound reporting should use recognised and recommended descriptive
terminology and include details of site, imaging size and nature of any
abnormality with an opinion as to the likely diagnoses and recommendations for
any further diagnostic procedure or intervention;
 participate in personal breast imaging audit and multidisciplinary breast service
audit;
 participate in CME as recommended by the RCR and ensure that this includes
an appropriate breast imaging content.
9.8.2 Radiologists involved in the NHSBSP
29
Professional standards for radiologists involved in the NHSBSP have been previously
established (Quality Assurance Guidelines for Radiologists in Breast Cancer Screening).
9.9 Equipment
This section provides guidance on equipment used for imaging as part of the routine
symptomatic breast assessment (x-ray mammography and breast ultrasound).
9.9.1 Imaging equipment sufficient for satisfactory diagnostic images
Radiologists involved in breast imaging should ensure that imaging equipment is of a
sufficient standard to achieve satisfactory diagnostic images. Breast imaging in
symptomatic practice should satisfy the technical and quality requirements laid down by
the NHSBSP.
9.9.2 Mammography equipment for symptomatic breast imaging and breast
screening assessment
For symptomatic breast imaging and breast screening assessment, mammography
equipment should be capable of:
 obtaining all conventional mammographic projections;
 obtaining specialist projections including localised compression, magnification
projections and stereotactic localisation (digital equipment for stereotaxis has
significant advantages);
 be subject to routine regular quality control assessment to the standards required
by the NHSBSP.
9.9.3 Ultrasound equipment for breast imaging
Ultrasound equipment used for breast imaging should:
 operate at a minimum of 7.5 MHz and preferably be capable of achieving 10-13
MHz operating frequency;
 provide either hard copy images of appropriate diagnostic quality or the facility to
archive and retrieve digital data;
 comply with the requirements laid down by IPEM 71;
 be subject to routine regular quality control assessment to the standards required
by the NHSBSP.
30
9.10 Appendix - Breast Radiologist Professional Standards
Professional standards for radiologists involved in breast imaging (Royal College of
Radiologists Breast Group)
Screening
In order to gain and maintain expertise,
each radiologist involved in screening
should fulfil the following criteria.
a) Be employed for a minimum of 3 or
preferably 4 or more notional half-days in
breast imaging.
b) Undertake a minimum of 5,000
screening and/or symptomatic cases a
year.
In addition, each radiologist should fulfil
the following criteria.
a) Have attended an RCR approved
course.
b) Be involved with assessment as well as
basic screening.
c) Be experienced in the use and
interpretation of sophisticated x-ray and
ultrasound procedures.
d) Have access to pathology follow-up
data.
e) Have access to surgical follow-up data.
f) Undertake formal audit of performance.
It would be advantageous also to meet the
following criteria.
a) Be involved with symptomatic breast
work.
b) Have skills in clinical examination.
c) Participate in an approved radiologists'
performance quality assurance scheme for
mammography.
Symptomatic imaging
In order to gain and maintain expertise
each radiologist involved in symptomatic
work should fulfil the following criteria.
a) Be employed for a minimum of 1 or
preferably more notional half-days in
breast imaging with time specifically
allocated for multidisciplinary breast
assessment.
b) Undertake a minimum of 500
symptomatic cases per year.
In addition, each radiologist should fulfil
the following criteria.
a) Have attended an RCR approved
course.
b) Be involved with assessment as well as
basic mammographic interpretation.
c) Be experienced in the use and
interpretation of sophisticated x-ray and
ultrasound procedures.
d) Have access to pathology follow-up
data.
e) Have access to surgical follow-up data.
f) Undertake formal audit of performance.
It would be advantageous also to meet the
following criteria.
a) Be involved with breast screening.
b) Have skills in clinical examination.
c) Participate in an approved radiologists'
performance quality assurance scheme for
mammography.
31
10.
Follow Up After Breast Cancer Treatment MVCN 2011
In drafting this document the NICE guidance on Early and Locally Advanced Breast
Cancer 2009 (CG80 & CG81) has been taken into account. It has been noted that NICE
recommendations are mostly based on the guideline development group’s consensus
and not on good quality data. MVCN follow-up policy is broadly in line with the NICE
recommendations with minor differences such as in the frequency of mammograms after
mastectomy. NICE guidance on follow-up is attached for reference purposes at the end
of the document.
10.1 MVCN NSSG Follow-up Guidelines
1. Follow-up after breast cancer treatment should be offered to every patient treated
by the breast unit.
2. This should include both mammograms and clinical examinations for invasive
cancers. It is acceptable to offer mammographic follow-up only for those treated
for DCIS. This would be in addition to the ongoing direct and telephone support
by the breast care nurse.
3. Clinical examination should be performed by appropriately trained members of
medical or nursing staff of the breast team. Follow-up mammogram quality
should be equal to that provided by the National Breast Screening Program and
should be reported by an appropriately trained member of radiology staff. It is
the responsibility of the lead clinician of each MDT to ensure that these
standards are maintained.
4. Patients should have the option of opting out of follow-up care in the secondary
care set up completely or have a “shared care” arrangement with primary care
where they could have all or most of the clinical examinations in primary care and
only attend the secondary care for mammography.
5. Patients treated for breast cancer should have an agreed, written care plan,
which should be recorded and regularly updated by a named healthcare
professional (or professionals) and given to the patient. This plan should include:
a. designated named healthcare professionals
b. dates for review of any adjuvant therapy
c. details of surveillance mammography
d. signs and symptoms to look for and seek advice on
e. contact details for immediate referral to specialist care
f. where relevant, contact details for support services, for example
lymphoedema.
Patients should be encouraged to take this document with them every
time they see a health care professional for a breast cancer related issue.
6. The mammographic follow-up should be annual for 5 years following the first
treatment (usually surgery). In those who have had a mastectomy, less frequent
mammograms are acceptable (such as 1 year, 3 years and 5 years following the
initial treatment). This is because nearly all local recurrences in these patients
are in the vicinity of the mastectomy scar thus not detected by mammography,
and the follow-up mammograms are done only to detect new cancers in the
contra lateral breast. Those patients who are not old enough to enter the National
Breast Screening Programme at the time of their 5-year mammogram would
continue to have mammograms done in the secondary care until they reach the
32
screening age. This would be annually for those who had BCS and at least
biannually for those who had a mastectomy.
7. Other imaging modalities (such as ultrasound or MRI) should not be used for
routine follow-up after breast cancer treatment regardless of the mode of
diagnosis of the original breast cancer. Occasional cases where such
investigations might be considered useful should be discussed and agreed in an
MDT.
8. Clinical follow-up should be for 5 years following the first treatment (usually
surgery). The frequency of visits should be at least 1-2 yearly. This may take
place in the primary care, secondary care or both.
9. There should be a local protocol in place in each MDT that makes the unit followup policy clear to all staff dealing with breast cancer.
10. Patients should have direct access (without having to go through the GP) to the
breast team that treated them via the key worker (usually the breast care nurse)
for a minimum period of 5 years following initial treatment. If the key worker felt
that the problem is best handled in the primary care, she / he would advice the
patient accordingly.
11. It is acknowledged that in patients with recurrent and / or metastatic disease, a
rigid follow-up policy is not possible as the intensity of follow-up would vary with
the severity of the disease, symptoms, treatment and other factors. An individual
approach as deemed fit by the oncologist would be used.
12. Clinical trial participants would be followed up as per the trial protocol.
10.2. NICE Guidance on Follow-up (for reference only)
10.2.1 Clinical Follow-up
•
Currently not all patients have the choice of where their clinical follow-up takes
place. Given choice, some women will opt for follow-up in primary care, others for
follow-up in secondary care, or even a shared system. It is important that choice,
as with other treatment decisions, is explored and patient preferences respected.
10.2.2 Clinical follow-up (hospital based)
•
The follow-up of breast cancer patients has been a topic of controversy for many
years and
•
each breast unit has had to formally develop follow-up policies as part of cancer
guidance.
•
These policies will have been agreed with primary care in some cases but all will
have been agreed across cancer networks. Although, as noted above, the
rationale for early detection of local recurrence is that treatment may be more
effective and there may be a survival benefit, there is no robust evidence that
follow-up in any specific setting reduces the rate of recurrence or improves
survival.
33
•
In the hospital setting patients are able to undergo clinical and radiological
review, prosthetic follow-up, supportive care and review of treatment plans
particularly where adjuvant therapies are prolonged or sequential.
•
Where breast care nurse specialists are now holding breast care clinics patients
also have the advantage of seeing the same person. Some patients may gain
considerable reassurance from being reviewed in a specialist setting with
healthcare professionals who have been responsible for their care from the
beginning.
10.2.3 Clinical follow-up (General Practice (GP) based)
•
An average practice of 10,000 patients will have around 23 registered patients
who consult their GP regarding their breast cancer each year. Most GPs wish to
provide follow-up for their patients with breast cancer if their concerns about
increased workload can be met, if clear guidelines for follow-up can be given,
and if assurances are given that patients will be seen urgently by the specialist
on an open access basis. The quality outcome framework [QOF] part of the GP
contract 20031 requires GPs to produce a register of cancer patients and to
document a review of patients within 6 months of confirmed diagnosis. The
review includes an assessment of support needs and co-ordination of
arrangements with secondary care. Fully computerised problem based records
are almost universal in primary care and greatly facilitate this process.
•
GP follow-up of women with breast cancer in remission is not associated with
increase in time to diagnosis of recurrence, increase in anxiety, or deterioration in
health related quality of life.
•
Most recurrences are detected by women as interval events and present to the
GP, irrespective of continuing hospital follow-up. GPs should be well placed to
provide continuity of care within the patients’ socioeconomic background and
taking account of other comorbidities.
•
Studies have shown no difference in outcome of patients followed up in GP
practice or in the hospital setting. NICE guidance (NICE 2002) advised that
breast cancer patients should be followed up in hospital setting for a minimum of
3 years. Some units, however, according to local policy continue to review
patients in the hospital-based setting, after this time for clinical and
mammographic surveillance.
10.3
Clinical Evidence
•
There is a reasonable volume of evidence available that is related to follow-up of
patients with breast cancer. A systematic review of mixed study design (Collins et
al., 2004) found that most patients expressed a preference for attending regular
follow-up sessions, even when asymptomatic. Although patients reported that the
anticipation of attending these routine sessions provoked anxiety, reduced fear of
recurrence and less physical and psychological distress was experienced after
attending their routine visit. A report on follow-up of a UK breast cancer charity
focus group (Breakthrough Breast Cancer, 2007) concluded that patients should
be given the information and support they need if they want to consider opting
out of follow-up care.
•
With respect to optimal frequency of follow-up, one systematic review of RCTs
concluded that the available trials are unable to indicate an ideal frequency of
34
follow-up (Montgomery et al., 2007). However the review cited trials that suggest
detection of recurrence is not affected by 3 monthly versus 6 monthly follow up,
nor by scheduled follow-up versus that available to patients on demand.
•
A Cochrane review (Rojas et al., 2000) found no statistically significant difference
in 5 year overall survival arising from routine follow-up versus intensive
(increased frequency and testing) follow-up regimens.
•
With respect to evidence about where follow-up should take place and who
should perform follow-up, one systematic review of RCTs concluded that
traditional routine clinic visits are an inefficient method of safeguarding against
recurrent disease. No difference in either total recurrences detected in hospital,
versus by the GP was reported, or in serious clinical events, or total number of
deaths (Montgomery et al., 2007). There was also no evidence for a difference in
either the total number of recurrences detected, or overall survival, when followup is performed by a doctor, compared to a breast care nurse specialist
(Montgomery et al., 2007). RCT evidence indicated that satisfaction is higher in
patients followed up by nurses than in those followed up by doctors, but that
quality of life is similar.
•
Evidence from qualitative studies also provided insight into the topic of effective
follow-up care for patients who had been treated for breast cancer. These studies
broadly described that checking for recurrence offering reassurance and
providing information were key elements required in follow up care (AdewuyiDalton et al., 1998; Beaver et al., 2005; Jiwa
•
et al., 2006; Kelly et al., 2006; Renton et al., 2002 and Vanhuyse et al., 2007).
10.4 Health Economic Evaluation
•
The GDG did not consider this topic as a health economic priority; therefore the
cost effectiveness literature on this topic has not been reviewed.
10.5 Recommendations
•
After completion of adjuvant treatment (including chemotherapy, and/or
radiotherapy where indicated) for early breast cancer, discuss with patients
where they would like follow-up to be undertaken. They may choose to receive
follow-up care in primary, secondary, or shared care.
•
Patients treated for breast cancer should have an agreed, written care plan,
which should be recorded by a named healthcare professional (or professionals),
a copy sent to the GP and a personal copy given to the patient. This plan should
include:
− designated named healthcare professionals
− dates for review of any adjuvant therapy
− details of surveillance mammography
− signs and symptoms to look for and seek advice on
− contact details for immediate referral to specialist care, and
− contact details for support services, for example support for patients
with lymphoedema.
10.6 Qualifying Statement
These recommendations are based on GDG consensus in the absence of any good
quality data.
35
11. Management of Locally Advanced Breast Cancer
11.1 Guidelines for the use of Neoadjuvant Chemotherapy
Neoadjuvant therapy (also known as pre-operative or primary systemic therapy) is
routinely used for locally advanced breast cancer. It should also be considered for
patients with primary operable breast cancer who would otherwise require a
mastectomy. In these patients down-staging may allow breast conservation. It may also
be considered for patients with tumours amenable for WLE and expected to receive
adjuvant chemotherapy. In these patients the benefit is to reduce the degree of surgical
resection and allow monitoring of response during therapy.
All patients considered for neoadjuvant chemotherapy should have a core biopsy to
establish presence of invasive breast cancer before commencing treatment.
The chemotherapy schedule used should be that which the clinician would have used for
that patient after surgery.
Patients should be reviewed every three weeks, before each cycle of chemotherapy, to
ensure that there is no disease progression.
If there is disease progression patients should be considered either for immediate
surgery or for change to taxotere 100mg/m2 every three weeks.
Patients with stable disease after three to four cycles of anthracycline-based
chemotherapy should be considered for a change to taxotere 100mg/m2 every three
weeks.
If there is any doubt regarding the clinical response patients should have a repeat
ultrasound and/or mammogram during the chemotherapy.
At the completion of the chemotherapy patients should have a repeat ultrasound and
mammogram to assess response and a decision made as to the most appropriate
surgical operation – either wide local excision or mastectomy.
For patients who are responding rapidly to chemotherapy a metallic clip should be
placed within the tumour by a radiologist to identify the area to be resected.
For patients who started with clinically involved / FNAC positive / /sentinel lymph node
positive axilla prior to chemotherapy axillary dissection should be performed, even if the
lymph nodes are longer palpable at the end of chemotherapy. For those without
involved nodes at diagnosis the options are: axillary dissection, radiotherapy or sentinel
node biopsy.
Breast radiotherapy should be recommended to all patients after wide local excision.
For patients who have had mastectomy radiotherapy considerations should be based on
the pre-chemotherapy tumour characteristics.
Adjuvant endocrine therapy and Herceptin should be considered according to guidelines
above, as would have been used for patients receiving adjuvant chemotherapy.
Er, PgR, HER2 should be performed if possible on the core biopsies. For those where it
is not possible or where oestrogen or progesterone results were negative they should be
performed on the surgically resected specimen.
36
11.2 Primary / Neoadjuvant Endocrine Therapy
Patients with large primary operable breast cancers who are over the age of 65, with ER
and/or PgR +ve tumours (particularly those with strong hormone receptor expression)
could be considered for an initial period of 4-6 months of letrozole 2.5mg daily prior to
surgery. Such treatment may allow tumour shrinkage which may then allow for breast
conserving surgery in a patient who would otherwise require a mastectomy.
This approach may also be appropriate for patients for whom immediate surgery is not
possible.
For some frail patients, or those unwilling to have surgery, treatment with letrozole
2.5mg daily until disease progression is appropriate.
37
12. Familial Breast Cancer
Nice guidelines 2006 (http://www.nice.org.uk/nicemedia/pdf/CG41quickrefguide1.pdf)
may be used to decide which woman (or man) with a family history requires referral
from primary to secondary care and from secondary care to a specialist genetics clinic
(Consultant Clinical Geneticist, Kennedy Galton Centre, Northwick Park Hospital) for
formal risk assessment, counselling, and where appropriate, genetic testing.
Women who meet the criteria and those referred back by the geneticist with a
recommendation for regular screening should be offered mammographic or both
mammographic and MRI screening as appropriate.
Prophylactic mastectomy with or without immediate reconstruction may be considered
by some women. They require appropriate counselling, and may need to be referred to a
psychologist prior to surgery. All reconstructive options should be explained to those
seeking a reconstruction. Two to three separate consultations are usually necessary.
38
13. Hypercalcaemia
Ensure adequate hydration.
Give IV disodium pamidronate in 500 mls normal saline by slow infusion as a single
infusion.
Dose of pamidronate should be adjusted according to degree of
hypercalcaemia, eg.
Adjusted Ca2+
<3mmol/L  15-30mg pamidronate
3-3.5mmol/L  30-60mg pamidronate
3.5-4mmol/L  60-90mg pamidronate
>4mmol/L  90mg pamidronate
* Maximum rate of infusion = 60mg/hour except if renal impairment maximum rate = 20mg/hour.
Pamidronate takes 4 to 5 days to achieve maximum effect and may be repeated if
necessary. Mild pyrexia occurs in approximately 15% of patients at 12 - 24 hours.
39
14. Breast Cancer Patient Information Pathways
14.1 Prevention and Risk Factors
Common Questions
 Abortion & breast cancer : the facts
 Alcohol and breast cancer : the facts
 Antiperspirants & deodorants and breast cancer : the facts
 Breast feeding and breast cancer : the facts
 HRT and breast cancer : the facts
 Menarche, menopause and breast cancer : the facts
 Obesity and breast cancer : the facts
 Pregnancy and breast cancer : the facts
 Soya, phyto-estrogens and breast cancer : the facts
 The pill and breast cancer : the facts
General Information
 Are you worried about breast cancer
 Breast cancer risk – what it means to you
 Doubtful risk factors
 Established risk factors
 Possible risk factors
14.2 Symptom Awareness and Early Detection
General Information
 Breast awareness – what it means to you and your body
 Breast cancer symptoms and early detection
 Breast cancer – spot the changes early
 Breast changes during and after pregnancy
 Taking good care – looking after your breasts
14.3 Screening



Breast screening : the facts
An easy guide to breast screening
Over 70? You are still entitled to breast screening
40
14.4 Referral, Tests and Investigations
General Information
 Referral to a breast clinic
 Letter, details of clinic & description of tests, key staff
Possible Tests
 Mammogram
 Ultrasound
 Referral to a breast clinic
14.5 Diagnosis and Staging
Other breast conditions
 Breast calcifications
 Breast cysts
 Breast pain
 Duct ectasia
 Fat necrosis
 Fibroadenoma
 Gynaecomastia
 Hyperplasia/atypical hyperplasia
 Intraductal papilloma
 Mondor’s disease
 Periductal mastitis
 Phyllodes tumour
 Sclerosis of the breast
Staging of breast cancer
 Diagnosis and staging of breast cancer
 Understanding your pathology report
 DCIS
 Inflammatory breast cancer
 Invasive lobular breast cancer
 LCIS
 Paget’s disease
 Breast cancer and you : diagnosis, treatment ad the future
 Breast cancer during pregnancy
 Men and breast cancer
 Men with breast cancer
 Younger women with breast cancer
41
14.6 Treatments
Specific treatments and side effects
 Arimidex (Anastrozole)
 Aromasin (Exemestane)
 CMF
 Faslodex
 FEC
 Femera (Leterozole)
 Fluorouracil (5FU)
 Gemzar (Gemcitabine)
 Herceptin (Trastuzmab)
 Medroxyprogesterone (Provera, Farlutal, Depo-Provera)
 Megestrol acetate
 Mitomycin
 Tamoxifen
 Taxol (Paclitaxel)
 Taxotere (Docetaxel)
 Vinorelbine (Navelbine)
 Xeloda (Capecitabine)
 Zolodex (Goserelin)
Radiotherapy
 Breast radiotherapy – side effects
 Radiotherapy
 Radiotherapy for breast cancer
Chemotherapy
 Chemotherapy for breast cancer
Hormone Therapy
 Hormone therapy for breast cancer
 Ovarian ablation and suppression
Surgery
 After breast reconstruction
 Breast reconstruction
 Breast reconstruction using body tissue
 Breast reconstruction with implants
 Risk reducing breast surgery
 Surgery for breast cancer
 Your operation and recovery
42
Clinical Trials
 Clinical trials and breast cancer
Supportive Therapies
 Bisphosphonates
 Leucovorin
General Information
 Breast cancer and hair loss
 Fertility issues and breast cancer treatment
 Menopausal symptoms and breast cancer
 Treating breast cancer
14.7 Follow-Up Care & Cancer in Remission
Diet & lifestyle
 Exercises after breast surgery
 Diet & breast cancer
Prosthetics & body image
 A confident choice : breast prostheses, bras and clothes after surgery
 Breast prosthesis & swimwear
 Breast prosthesis ; local services
Lymphoedema
 Breast oedema
 Coping with lymphoedema following mastectomy or lumpectomy
 Living with lymphoedema after breast cancer
 Lymphoedema
General Information
 After treatment for breast cancer
 Discharge and follow-up plan
Other
 Osteoporosis and breast cancer
14.8 Advanced Cancer & Recurrence









Secondary breast cancer
Secondary breast cancer symptoms & diagnosis
Secondary breast cancer treatment overview
Secondary breast cancer treatments
Secondary breast cancer symptom control
Secondary bone cancer
Secondary brain cancer
Secondary liver cancer
Secondary lung cancer
43
14.9 All Stages
Support & Information
 Breast Care CNS and MDT team
 Local information and support services directory
Feelings, emotions & communication
 Talking to your children about breast cancer
Carers & partners, relationships & sexuality
 In it together – information for partners
 Sexuality, intimacy and breast cancer
Finance & Employment
 Breast cancer and benefits
 Breast cancer and childcare
 Breast cancer and travel insurance
Complementary Therapies
 Complementary therapies & breast cancer
Breast Cancer & Family History
 Breast cancer in families
 Concerned about a family history of breast cancer
Other breast cancer information
 The best treatment – hormone therapy
 The best treatment – radiotherapy
 The best treatment – referral
 The best treatment – surgery
 The best treatment – chemotherapy
 The best treatment – financial issues
 The best treatment – follow-up
 Questions & Answers
 Standards of care for young women with breast cancer
44
Appendices
Appendix 1 - TNM Staging
Primary tumor (T):
TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis:
Carcinoma in situ; intraductal carcinoma, lobular carcinoma in situ, or Paget's
disease of the nipple with no associated tumor.
Note: Paget's disease associated with a tumor is classified according to the size
of the tumor.
T1: Tumor 2.0 cm or less in greatest dimension
T1mic: Microinvasion 0.1 cm or less in greatest dimension
T1a: Tumor more than 0.1 but not more than 0.5 cm in greatest dimension
T1b: Tumor more than 0.5 cm but not more than 1.0 cm in greatest dimension
T1c: Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension
T2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension
T3: Tumor more than 5.0 cm in greatest dimension
T4: Tumor of any size with direct extension to (a) chest wall or (b) skin, only as
described below.
Note: Chest wall includes ribs, intercostal muscles, and serratus anterior muscle
but not pectoral muscle.
T4a: Extension to chest wall
T4b: Edema (including peau d'orange) or ulceration of the skin of the breast or
satellite skin nodules confined to the same breast
T4c: Both of the above (T4a and T4b)
T4d: Inflammatory carcinoma*
Regional lymph nodes (N):
NX: Regional lymph nodes cannot be assessed (e.g., previously removed)
N0: No regional lymph node metastasis
N1: Metastasis to movable ipsilateral axillary lymph node(s)
N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or
to other structures
N3: Metastasis to ipsilateral internal mammary lymph node(s)
Pathologic classification (pN):
pNX: Regional lymph nodes cannot be assessed (not removed for pathologic
study or previously removed)
pN0: No regional lymph node metastasis
pN1: Metastasis to movable ipsilateral axillary lymph node(s)
pN1a: Only micrometastasis (none larger than 0.2 cm)
pN1b: Metastasis to lymph node(s), any larger than 0.2 cm
pN1bi: Metastasis in 1 to 3 lymph nodes, any more than 0.2 cm and all
less than 2.0 cm in greatest dimension
pN1bii: Metastasis to 4 or more lymph nodes, any more than 0.2 cm and
all less than 2.0 cm in greatest dimension
pN1biii: Extension of tumor beyond the capsule of a lymph node
metastasis less than 2.0 cm in greatest dimension
pN1biv: Metastasis to a lymph node 2.0 cm or more in greatest dimension
45
pN2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other
or to other structures
pN3: Metastasis to ipsilateral internal mammary lymph node(s)
Distant metastasis (M):
MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis present (includes metastasis to ipsilateral
supraclavicular lymph nodes)
AJCC stage groupings
Stage 0
Tis, N0, M0
Stage I
T1,* N0, M0
*T1 includes T1mic
Stage IIA
T0, N1, M0 T1,* N1,** M0 T2, N0, M0
*T1 includes T1mic **The prognosis of patients with pN1a disease is similar to
that of patients
with pN0 disease.
Stage IIB
T2, N1, M0
T3, N0, M0
Stage IIIA
T0, N2, M0 T1,* N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0
*T1 includes T1mic
Stage IIIB
T4, Any N, M0
Any T, N3, M0
Stage IV
Any T, Any N, M1
46
Appendix 2 - Chemotherapy Schedules
CMF
Cyclophosphamide * 100 mg/m2 (max 150mg) PO daily day 1 to 14.
Methotrexate 40 mg/m2 IV bolus days 1 and 8
5FU 600 mg/m2 IV bolus days 1 and 8
Repeat every 28 days
Give Folinic Acid 15mg orally 24 and 36 hours after Methotrexate
If necessary can give Cyclophosphamide intravenously in this regime (instead of orally)
in a dose of 600mg/m2 on day 1 and 8.
*Some consultants give Cyclophosphamide 100mg orally daily on days 1 to 14
(regardless of surface area).
2.
FEC
(i) Adjuvant:
5FU 500mg/m2 IV bolus - day 1
Epirubicin 75mg/m2 IV bolus - day 1
Cyclophosphamide 500mg/m2 IV bolus - day 1
Repeat every 21 days
(ii) Metastatic: 5FU 500mg/m2 IV bolus day 1
Epirubicin 50-75mg/m2 IV bolus day 1
Cyclophosphamide 500mg/m2 IV bolus day 1
Repeat every 21 days
Adjust Epirubicin dose if bilirubin levels raised
3. MMM
2
Methotrexate 30 mg/m (max 45 mg) IV bolus day 1
Mitozantrone 7 mg/m2 IV infusion day 1
2
Mitomycin C 7 mg/m IV bolus day 1
Repeat Methotrexate/Mitoxantrone every 21 days
Repeat Mitomycin C every 6 weeks only
Give Folinic Acid 15mg orally 24 and 36 hours after Methotrexate
NB. If patient is on Tamoxifen because of  risk of haemolytic
uraemic syndrome, omit mitomycin C and use MM (with  dose of mitoxantrone)
Adjust Mitoxantrone doses if bilirubin levels raised
48
4. MM
Methotrexate 30mg/m2 (max 50mg) IV bolus day 1
Mitoxantrone 11mg/m2 IV infusion day 1
Repeat every 21 days
*Give Folinic Acid 15mg/ orally 24 and 36 hours after MTX
* Adjust Mitoxantrone dose if bilirubin levels raised
5. AC
Adriamycin 60mg/m2 IV bolus day 1
Cyclophosphamide 600mg/m2 IV bolus day 1
Repeat every 21 days
Adjust Adriamycin dose if bilirubin levels raised
6. EpiCMF
Epirubicin 100mg/m2 IV bolus day 1
Repeat every 21 days for four cycles
To be followed by four cycles of CMF, as described above
7. Taxotere
Taxotere 75-100mg/m2 iv
1 hour infusion
Repeat every 21 days
Premedication: 8mg bd dexamethasone oral 3 days, starting night before
+ 8mg iv 1 hour prior to infusion
8. Taxol
Paclitaxel (Taxol) 175 mg/m2 iv
3 hour infusion
Repeat every 21 days
Premedication: dexamethasone 20mg po either night before and morning
before treatment, or 20mg iv 30 minutes before paclitaxel
+ 30 minutes prior to paclitaxel: chlorpheniramine 10mg iv
and ranitidine 50mg iv
9. Vinorelbine (single agent)
Vinorelbine 25-30mg/m2 iv
5-10 minute infusion
Day 1 and 8 every three weeks
10. Gemcitabine and Carboplatin
Gemcitabine 1000mg/m2 day 1 and day 8 iv
48
Carboplatin AUC 4-5 iv day 1
Repeat every 21 days.
Guidelines for G-CSF
Growth factors are not routinely used for breast cancer patients.
Growth factors may be used in the adjuvant setting to maintain dose intensity for
patients who have already had a 25% dose reduction.
Growth factors may also be used in patients who have experienced neutropenic sepsis.
For patients receiving adjuvant FEC chemotherapy (500/75/500) if dose reduction is
necessary the 5FU and cyclophosphamide doses should be kept the same and
epirubicin reduced to 60mg/m2 – this dose maintained using GCSF.
For the FEC(100)/Docetaxel(100) if patients develop neutropenia requiring a delay or
develop neutropenic sepsis then the dose should be maintained with GCSF.
Guidelines for cardiac function assessment
Consider MUGA scan or echocardiography prior to anthracyclines, taxanes, herceptin.
ECG according to hospital guidelines (refer to Black Book)
49
Appendix 3: Oncological Emergencies
The Neutropenic Patient
For full policy please refer to: Mount Vernon Cancer Centre Policy & Procedures folder –
‘Guidelines for the use of Antimicrobials in Neutropenic Patients’
1. All patients should be prescribed Ceftazidime except in those with a well
documented severe penicillin/cephalosporin reaction (discuss alternative antibiotic
with a microbiologist).
Ceftazidime 2gm iv tds
If the patient becomes severely unwell (at anytime) add in Gentamicin.
2. Teicoplanin should only be added if:
 Gram positive organisms are seen/isolated from blood cultures whilst
sensitivities are awaited
 There is cellulitis, especially of any central line exit site if applicable
 Fever/rigors occurs related to central line usage (eg. on flushing)
Note: Teicoplanin can be stopped if subsequent sensitivities show sensitivity to
Ceftazidime.
Teicoplanin 400mg iv 12hourly for 3 doses then 400mg iv daily
If renal function is impaired, the same loading dose but reduced maintenance
dose from day 4 of treatment should be prescribed, as below:
GFR 40 – 60ml/min Teicoplanin 400mg iv alternate days
<40ml/min Teicoplanin 400mg every 3rd day
3. If by 72 hours the patient is not settling and the temperature remains >38oC
intravenous antifungals should be considered
4. Antibiotics may need to be changed but this should not be routine
If considered appropriate, change Ceftazidime and Gentamicin to: Ciprofloxacin
400mg iv bd and Amikacin 7.5mg/kg iv bd with Amikacin levels being monitored OR
Meropenem 1gm iv tds according to local preference.
If the patient develops septic shock at any time, immediate microbiological advice should
be sought.
Thrombocytopenia
Patients receiving chemotherapy should also be warned of risk of thrombocytopenia
Consider administering platelets if:
i) Platelets 15-30 x 109/litre and patient has signs of bleeding or is septic
ii) Platelets < 15 x 109/litre
iii) Platelets are <50 x 109/L and the patient requires a lumbar puncture or other invasive
procedure
Administration of any platelets needs to be discussed with Haematologist. In all cases
try to give advance warning of anticipated needs. This is particularly important at
weekends.
50
Appendix 4 - Calculation of the Dose in the Axilla
For 6 MV:
Maximum dose 105% at build up depth (may occur if 80% dose prescribed to mid axilla)
Prescribed
Dose
(Gy)
50
40
41.6
39
Number of
fractions
Max dose per
fraction
/ = 2Gy
/ = 3.5Gy
25
15
13
13
(Gy)
2.1
2.8
3.36
3.15
EDQ2Gy
53.8
50.4
58.5
52.7
EDQ2Gy
53.5
48.1
54.5
49.5
Maximum dose 107% at build up depth (may occur if 85% dose prescribed to mid axilla)
Prescribed
Dose
(Gy)
50
40
41.6
39
Number of
fractions
Max dose per
fraction
/ = 2Gy
/ = 3.5Gy
25
15
13
13
(Gy)
2.14
2.85
3.42
3.21
EDQ2Gy
55.4
51.9
60.3
54.4
EDQ2Gy
54.9
49.4
55.9
50.9
Table 2 - ratios to achieve mid axilla nominal dose of 85%
Separation
(cm)
11
12
13
14
15
16
17
18
19
20
Ratio of applied doses
Ant s’clav
1
10
10
10
10
8
7
7
4
4
Post axilla
0
1
1
1
1
1
1
1
1
1
MPD
%
ICRU
Maximum (%)
85.6
91.6
89.2
87.6
85.2
85
85
84.2
86.6
85
100
106
106
106
105.5
106.5
107
107
110.5
110
It is recommended that for axillary separations of 19cm and above, the ratios from table
1 (not table 2) should be used ensuring a mid axillary nominal dose of 80% whilst
keeping the maximum dose and dose at 3cm within tolerance. The above table is for 6
MV x-rays.
51
Appendix 5 - MVH: Breast Presentation Sheet
Affix label or give patient details:
Patient name:
Hospital Number:
Dob:
(R)
(L)
Tel No:
Age:
MVH No:
Referred by:
Stage at presentation:
T ____ N ____ M ____
Clinical tumour:
______ cm
Family History:
No / Yes - specify
Past Medical History:
___________________________________
Menopausal status:
Prem / Perim (LMP, < 2yr) / Post m / Unevaluable
Medication:
___________________________________
Site of primary tumour (see diagram)
Screen detected: Yes / No
Investigations:
CXR: _________ Bone scan: __________ LFTs: __________ Liver u/s: _________ Other: _________
Mammography:
______________________
(N = Normal, ND = Not Done, AB = Abnormal)
Primary Treatment:
Primary surgery:
excision / mastectomy / none
Date of surgery: ___ / ___ / ___
Pathological tumour:
____ cm / not stated
Excision (macroscopic):
complete / incomplete / marginal / not stated
(microscopic):
complete / incomplete / marginal / not stated
Pathological type:
ductal ca. / lobular ca. / mixed / other
Tumour grade:
1 / 2 / 3 / not stated
ER:
______ + /  / Not known
Intraduct component:
Yes / No / not stated
PGR:
______ + /  / Not known
Lymphatic or vascular permeation: Yes / No / not stated
HER2 : ______ 3+ / 2+ / 1+ / 0
Axillary surgery:
Yes / No
Lymph nodes removed:
_______
Re-excision
Yes / No ______________
Pathological stage:
T_____ N_____ M _____
Lymph nodes involved: ______
Treatment Plan:
Local regional RT:
breast / chest wall / axilla / SCF / none
Adjuvant systemic therapy: endocrine / cytotoxics / none
Trial: _____________________
Comments:
offered:
Yes / No
accepted:
Yes / No
Consent:
Radiotherapy:
Yes / No
B Form:
Yes / No
Chemotherapy:
Yes / No
C Form:
Yes / No
Dr's Signature: ________________________
Date: ____/____/____
52
Appendix 6 - Effects Of Adjuvant Tamoxifen and Chemotherapy
Proportional effects of adjuvant tamoxifen and chemotherapy as reported in the
most recent overviews
Reduction in Annual Odds (%)
of
Recurrence
Death
Ovarian ablation vs. no ovarian ablation
Age <50, ER+ and Tamoxifen for > 2 years vs. no tamoxifen
Age < 50, ER + or unknown
Age 50 +, ER + or unknown
Tamoxifen for  5 years vs. no tamoxifen
Age < 50, ER+ or unknown
Age 50+, ER+
Combination chemotherapy for > 4 months vs.
no chemotherapy
Age ¸50, ER+ and Age 50+, ER+ and Tamoxifen + chemotherapy vs. chemotherapy
alone
Age < 50
Age 50+
Chemotherapy + tamoxifen* vs. Tamoxifen*
alone
Age < 50
Age 50+
*Tamoxifen for 2 years or more
Abbreviation: ER, estrogen receptor
25  7
24  7
45  5
34  3
10  6
19  3
45  6
47  3
32  10
26  4
34  4
20  3
27  5
10  3
40  19
54  8
39  22
49  10
21  13
19  3
25  14
11  4
Absolute effects of adjuvant tamoxifen and chemotherapy as reported in the most
recent overviews
Absolute Mortality Reduction
(%)*
Node Node +
Ovarian ablation vs. no ovarian ablation
Age <50, all ER groups
5.6  4.0
Tamoxifen for > 2 years vs. no tamoxifen
All ages, ER+ or unknown
2.3  1.3
Tamoxifen for  5 years vs. no tamoxifen
All ages, ER+ or unknown
5.6  1.3
Combination chemotherapy for > 4 months vs.
no chemotherapy
Age < 50 ER+ and 5.7  2.1
Age 50+ ER+ and 6.4  2.3
* Difference on the life table plots at 10 years
Abbreviation: ER, estrogen receptor
12.5  3.9
7.2  1.2
10.9  2.5
12.4  2.4
2.3  1.3
53
Appendix 7 - Use of Taxanes for Breast Cancer: Guidance Issued By Nice
Adjuvant (March 2009) (www.nice.org.uk/CG80)
Offer docetaxel to patients with lymph node-positive breast cancer as part of an adjuvant
chemotherapy regimen.
Do not offer paclitaxel as an adjuvant treatment for lymph node-positive breast cancer.
Metastatic (June 2000)
Either Docetaxel (Taxotere) or Paclitaxel (Taxol) should be used in advanced breast
cancer where initial cytotoxic chemotherapy, including anthracycline, has failed or is
inappropriate.
The decision on which drug to use should be taken by the clinician in consultation with
the patient, bearing in mind the evidence summarised in NICE guidance.
54
Appendix 8 - Use of Vinorelbine for the Treatment of Advanced Breast Cancer :
Guidance Issued By Nice (December 2002).
Vinorelbine monotherapy is not recommended as a first-line treatment for advanced
breast cancer.
Vinorelbine monotherapy is recommended as one option for second-line or later therapy
for the treatment of advanced breast cancer when anthracycline-based regimens have
failed or are unsuitable. The choice of appropriate second-line or later treatment for
advanced breast cancer should be made jointly by the patient and the clinician
responsible for treatment after an informed discussion of the relative benefits of the
available drugs and their side-effect profiles.
The present state of evidence does not allow the Institute to recommend the routine use
of vinorelbine combination therapies.
55
Appendix 9 - Use of Herceptin: Guidance Issued By Nice
Trastuzumab in combination with paclitaxel (combination trastuzumab is currently only
licensed for use with paclitaxel) is recommended as an option for people with tumours
expressing human epidermal growth factor receptor 2 (HER2) scored at levels of 3+ who
have not received chemotherapy for metastatic breast cancer and in whom anthracycline
treatment is inappropriate.
1.2 Trastuzumab monotherapy is recommended as an option for people with tumours
expressing HER2 scored at levels of 3+ who have received at least two chemotherapy
regimens for metastatic breast cancer. Prior chemotherapy must have included at least
an anthracycline and a taxane where these treatments are appropriate. It should also
have included hormonal therapy in suitable oestrogen receptor positive patients.
1.3 HER2 levels should be scored using validated immunohistochemical techniques and
in accordance with published guidelines. Laboratories offering tissue sample
immunocytochemical or other predictive tests for therapy response should use validated
standardised assay methods and participate in and demonstrate satisfactory
performance in a recognised external quality assurance scheme.
56
Appendix 10 - Use of Capecitabine for the Treatment of Locally Advanced or
Metastatic Breast Cancer: Guidance Issued By NICE (May 2003)
1.1 In the treatment of locally advanced or metastatic breast cancer, capecitabine in
combination with docetaxel is recommended in preference to single-agent docetaxel in
people for whom anthracycline-containing regimens are unsuitable or have failed.
1.2 Capecitabine monotherapy is recommended as an option for people with locally
advanced or metastatic breast cancer who have not previously received
capecitabine in combination therapy and for whom anthracycline and taxanecontaining regimens have failed or further anthracycline therapy is contraindicated.
1.3 The decision regarding treatment should be made jointly by the individual and the
clinician(s) responsible for treatment. The decision should be made after an
informed discussion between the clinician(s) and the patient; this discussion should
take into account contraindications and the side-effect profile of the agents,
alternative treatments for locally advanced or metastatic breast cancer, and the
clinical condition and preferences of the individual.
1.4 The use of capecitabine to treat locally advanced or metastatic breast cancer
should be supervised by oncologists who specialise in breast cancer.
57
Appendix 11 - Mount Vernon Cancer Network: Recommendations for use of
Hormone Antagonists for Early Breast Cancer
Intervention
Licensed Indications
(1)
Tamoxifen
(Generic)
Adjuvant treatment of
breast cancer in
oestrogen receptor
positive women.
Adjuvant
treatment of ER
positive early
breast cancer in
postmenopausal
women.
Adjuvant
treatment of early
breast cancer in
hormone receptor
positive
postmenopausal
women who have
received 2 to 3
years of adjuvant
tamoxifen
Anastrozole
(Arimidex)
Letrozole
(Femara)
Adjuvant
treatment of ER
positive early
breast cancer in
postmenopausal
women.
Early invasive
breast cancer in
postmenopausal
women after
standard adjuvant
tamoxifen therapy.
Pre-operative
treatment in
postmenopausal
women with
localised
hormone-receptorpositive breast
cancer to allow
subsequent breast
conserving
surgery.
Exemestane Adjuvant
Mount Vernon
Cancer Network
Recommendation
(2,3)
Use first line for
max 5 years but
see below.
Comments
Cost £
28days(4,5)
(as of May
09)
£2.73
Use first line in
early invasive
breast cancer if
unable to take
tamoxifen (ie high
risk of VTE or
endometrial
abnormalities) or
become intolerant
to tamoxifen or
high-risk breast
cancer patients* for
5 years.
Use after two to
three years of
tamoxifen therapy
for total of 5 years if
high risk factors**
Consider use in
node positive ER
and or PgR positive
breast cancer
patients who
complete 5 years of
tamoxifen therapy,
for a further 3
years.
*Node
positive
and/ or
grade III
tumours
and/or
HER-2 +ve
£68.56 / 28
days (£2.45
/ day)
**Node
positivity,
grade III,
tumour size
>2cm
£66.50 / 28
days
(£2.38 /
day)
Primary endocrine
therapy: patients
with large primary
operable breast
cancers > 65 years
old, ER and/or PgR
+ could be
considered for 4-6
months of Letrozole
prior to surgery (to
allow breast
conserving surgery)
Use after two to
**node
£88.30 /30
58
(Aromasin)
treatment of ER
positive early
breast cancer in
postmenopausal
women following
2–3 years of
tamoxifen therapy.
three years of
tamoxifen therapy
for total of 5 years if
high risk factors**
positivity,
grade III,
tumour size
>2cm
days (£2.96
/ day)
59
Appendix 12 - Royal Marsden Guidelines (RMH) guidelines for AI and post treatment amenorrhoea
Smith, I.E., et al., Adjuvant aromatase inhibitors for early breast cancer after chemotherapy-induced amenorrhoea: caution and suggested
guidelines. J Clin Oncol, 2006. 24(16): p. 2444-7.
CHEMOTHERAPY-INDUCED AMENORRHOEA
RMH GUIDELINES
<40 years
Avoid AI alone.
Only
use
in
combination
with
ovarian
suppression
Trial entry
e.g. SOFT
trial
Tamoxifen
40-50years
>50years
Validated
suprasensitive
oestradiol assay
???
YES
Baseline oestradiol &
gonadotrophins
NO
Oestradiol >20pmol/L
Normal
gonadotrophins
Oestradiol <10pmol/L
Elevated gonadotrophins
Avoid AI alone.
Only use in
combination with
ovarian
suppression
Trial entry e.g. SOFT
trial
Stop AI if
oestradiol rises
AI with serial measurement oestradiol,
LH, FSH for 6 months or longer if
previous tamoxifen
Appendix 13 - Recommendations for Vaccinations in Patients Undergoing Chemotherapy
The following recommendations were suggested (Jan.2004) for all patients undergoing chemotherapy:
1)
Live vaccines may replicate in immunosuppressed patients, and are therefore not recommended in patients who:
A: have received chemotherapy or generalised radiotherapy in the
last 6 months or
B: have received a bone marrow transplant in the last 6 months or
C: have received the equivalent of 40mgs Prednisolone for 1 week
or more – should not receive live vaccines for 3 months after
immunosuppressive treatment stopped.
2)
Inactivated vaccines are considered safe in chemotherapy
patients, although patients should be warned that protection provided may not be adequate due to reduced immune response. In
particular, the ‘flu vaccine has been found to be safe, and reasonably effective in patients undergoing chemotherapy.
The recommendation for receiving ‘flu vaccines are as follows:
All patients receiving chemotherapy of any sort should be offered ‘flu vaccines, especially if they are over 65 years or have co-morbid respiratory
or cardiac conditions.
Patient should ideally be vaccinated 2 or more weeks before chemotherapy starts; however, it is safe to vaccinate patients between courses of
chemotherapy.
61
Appendix 14 - Breast Radiotherapy Competency Pro Forma
NAME OF TRAINEE:
YEAR OF TRAINING:
NAME OF ASSESSOR:
DATE OF ASSESSMENT:
1. INDICATIONS FOR TREATMENT- Trainee understands the rationale and indications for radiotherapy
in breast cancer (breast, chest wall, axilla, SCF, palliative breast etc.) and the relevant anatomy
2. PRE-PLANNING PREPARATION – Trainee should be able to discuss assessing fitness for treatment,
contraindications to radiotherapy, obtaining informed consent, the use of pre-operative, operative and
histological information to determine treatment, necessity for breast cup etc.
3. RADIOTHERAPY PLANNING PROCESS – Trainee should be able to explain the CT and
conventional planning process for breast/chest wall/axilla (anterior and posterior fields)/SCF
radiotherapy and breast boost including intended target volume, marking up of treatment field borders,
methods for matching tangential breast fields and axilla/SCF field etc.
4. ORGANS AT RISK (OARS): Trainee understands OARS (lung, heart, spinal cord, brachial plexus for
glands fields) and accepted volumes/doses to each.
5. PRESCRIBED DOSE: Trainee demonstrates knowledge of differing fractionation regimes and
chooses appropriate fractionation according to clinical circumstances.
6. PLAN CHECK: Trainee is able to assess correctly the dose homogeneity in the plan and assess
hotspots, OARs, beam energies/wedges etc.
7. ON SET VERIFICATION: Trainee is able to assess the initial treatment image (electronic portal image
– EPI) as being within acceptable geometric tolerance and make appropriate recommendations if EPI
outside protocol limits.
8. TOXICITY ASSESSMENT and POST RADIOTHERAPY FOLLOW-UP: Trainee understands acute
and late side-effects and their management; has knowledge of local follow-up policy
EVIDENCE OF COMPETENCY ACHIEVED
This will vary between trainees, but would be expected to include demonstration that the trainee has read and
understood the MVCN breast treatment protocols; a review of the evidence gathered in the trainee logbook;
direct observation of the trainee over an appropriate period of time; direct discussion with the trainee,
including clinical scenarios
61
STATEMENT:
I, …………………………………………………………………………….., agree the following SpR has been
appropriately assessed against the MVCC competency framework and is able to act as a practitioner as
defined by the departments IRMER procedures in the area of breast treatment
SIGNED:
DATE:
I, …………………………………………………………………………………, agree with above assessment. I
confirm that I have been appropriately assessed and understand my responsibilities as indicated by the
MVCC IR(ME)R procedures. I undertake to maintain my competency in a professional fashion
SIGNED:
DATE:
Appendix 15 - Guidelines for the Handling and Pathological
Reporting of Breast Cancer Specimens, MVCN Breast NSSG 08-1C106b
1. Specimen Handling
1. Breast specimens should be orientated by surgeons prior to being sent to pathology. This could be by
using sutures and / or clips but care must be taken with clips so they do not fall off. The pattern of orientation
should be agreed between the surgeon and the pathologist. If the preoperative diagnosis is DCIS it is helpful
if the surgeon marks the nipple duct margin.
2. Reporting pathologist should have access to the specimen x-ray.
3. All breast biopsy specimens should be weighed by the laboratory and results incorporated in the report.
4. It is anticipated that lesions will be resected according to a defined surgical protocol. If the surgical
resection differs from the protocol, e.g. if dissection does not extend to the deep fascia or skin when this is
the norm, this should be clearly indicated on the request form.
5. If more than one piece of tissue is removed (e.g., cavity shavings), it should be made clear how the
samples are orientated with respect to each other in order to simplify assessment of the size of the lesion and
distance to margins.
6. The specimen should be sent to the pathology according to the local protocol; either immediately in the
fresh state or in a fixative whose volume is at least twice that of the specimen size. In the latter circumstance
especially with mastectomy specimens, and by arrangement with the pathologist, consideration should be
given to allowing the surgeon to make a controlled single or cruciate pair of incisions into the posterior aspect
of the lesion, thus preserving the integrity of key margins while allowing immediate penetration of fixative.
2. Laboratory Handling
• The entire surface of the specimen should be inked so that the margins of excision can be easily
determined. This can be performed by prior removal of surface lipid by dipping the specimen in alcohol and
drying and then applying an appropriate pigment such as Indian ink, Alcian blue, dyed gelatine
or a multiple ink technique. Indian ink can be fixed after painting using 10% acetic acid.
• Good fixation is vital to preserve the morphological detail. Specimens must be placed in sufficient formalin
(twice the volume of the specimen) or other appropriate fixative inside an appropriately sized and shaped
container either before or, preferably, after receipt by the laboratory.
a. Diagnostic Localisation Biopsies
• The specimen should be weighed and measured and then, usually, serially sliced at intervals of
approximately 3–5 mm.
• Cases where block selection is required (i.e. those that are not embedded in their entirety) will benefit from
specimen slice x-ray examination, particularly those with an impalpable mammographic lesion such as
microcalcification. This enables blocks to be taken from the areas corresponding to the mammographic
abnormality, as well as any other suspicious areas identified.
• The sites of sampling can be marked on the specimen x-ray or the x-ray of specimen slices by using a white
wax (Chinagraph) pencil or other marker.
• The sampling technique and the number of blocks taken are clearly dependent on the size of the specimen
and the size of the abnormality. If the specimen is small, it is often best to block and examine all of the tissue.
Samples of approximately 30 mm or less in maximum dimension should be completely sliced, embedded and
examined histologically.
• For larger specimens, sampling should be adequate to determine accurately the size of the lesion.
Sampling should include the extremes of the mammographic abnormality and adjacent tissue in order to
avoid underestimation of size. This is particularly important with cases of DCIS as it is recognised that
mammographic size may be an underestimate of true tumour size.
• If specimens are sent as more than one piece of tissue, it can be impossible to measure the absolute extent
of the lesion. In these cases, it is appropriate to take a pragmatic approach and to measure the maximum
size in each piece of tissue and add the dimensions to give an estimated total size. If, however, the
orientation of the specimens can be determined, the true size can be ascertained more reliably.
b. Therapeutic Wide Local Excision
• The specimen should be weighed and measured in three dimensions.
• The technique for sampling the abnormality will vary somewhat according to type of sample and specimen
size and also according to pathologist/laboratory preference, therefore a degree of flexibility is required.
Several options are available. Whichever is utilised, as an absolute minimum, the information for the breast
cancer minimum dataset, including accurate measurement of size and detailed examination of the margin
status and distance to margins, must be provided.
• The specimen can be sliced either before fixation or after fixation and marking of the excision margins. The
specimen is sliced at intervals of approximately 3–5 mm, usually perpendicular to the medial–lateral axis in
the anterior–posterior plane.
• These specimens may benefit from specimen slice radiographic examination.
• If the excision has been undertaken for calcification or for known DCIS, blocks should be taken to include
areas of fibrous breast tissue proximal and distal to the calcification. DCIS, especially the low grade type,
may be much more extensive than the radiologically apparent calcification.
• Blocks should be taken from the main area of calcification and also from proximal (towards the nipple) and
distal to the calcification as DCIS extends most frequently in this plane. Measurement can be made in this
way from the most distal involved duct across the main area of calcification to the most proximal involved
duct.
• The number of blocks taken will depend on the size of the specimen and the size of the abnormality. If the
specimen is small, it is often best to block and examine all of the tissue. Samples 30 mm or less in maximum
dimension can be completely sliced, embedded and examined histologically.
• For larger specimens, sampling should include the extremes of the
Mammographic / palpable abnormality and adjacent tissue in order to avoid underestimation of the size of a
lesion. This is particularly important as it is recognised that mammographic size may be an underestimate of
true lesion size.
• If therapeutic samples are sent in more than one portion, it can be extremely difficult to measure the
absolute largest extent of the whole lesion present. In these cases, it is appropriate to measure the maximum
distance in any piece of tissue and to add the dimensions to give an estimated total size. If, however, the
orientation of the specimens can be determined, the size can be ascertained more reliably.
• The margins of therapeutic excision specimens should also be sampled. The nearest margin to the
abnormality must be blocked, as an absolute minimum, in order to facilitate measurement of this distance.
Preferably, the margins should be more widely sampled to allow more accurate assessment of adequacy of
excision. Examination of the margin closest to the nipple may also be valuable.
• The use of different colour inks/markers on an individual section can assist microscopic identification of
specific margins.
• The specimen is usually incised from the posterior deep fascial plane in a cruciate fashion through the
centre of the tumour. This allows the tumour to be sampled as four blocks, which include the anterior–
posterior, medial–lateral and superior–inferior dimensions.
• It may be possible to take radial margin and the lesion in one block from smaller resections. Larger
specimens may require tumour and margin blocking in two (or more) cassettes.
• Sections taken for measurement of distance to margins will include a slice through the lesion to the radial
edges of the specimen and will allow measurement of the lesion to margin distance.
• One or more additional radial blocks extending to the closest margin
(superolateral, superomedial, inferomedial, inferolateral) should be taken if these are the closest.
• For larger specimens, sampling should include the extremes of the abnormality and adjacent tissue in order
to avoid underestimation of the size of a lesion.
• The circumferential edge of the sample can be shaved to allow more extensive examination of relevant
surgical resection margins. Alternatively, the surgeon may provide cavity shaves. This can produce a series
of additional shave/cavity blocks: superior shave, superolateral shave, lateral shave, inferolateral shave,
inferior shave, inferomedial shave, medial shave, and superomedial shaved edges, depending on the size of
the specimen. The site of each specimen should be clearly labelled and each specimen examined separately.
• It should be noted that shaved edges of the margins of the specimen or examination of ‘cavity shaves/bed
biopsies’ assess adequacy of excision but do not allow measurement of distance between tumour and
margins.
c. Mastectomy Specimens
• The specimen is conventionally incised from the posterior deep fascial
plane in a cruciate fashion through the centre of the tumour. Alternatively, the whole specimen can be cut at
approximately 1 cm intervals. The cruciate technique allows the tumour to be sampled as well fixed blocks,
which include the anterior–posterior, medial– lateral and superior–inferior dimensions.
• The apparently normal portion of the mastectomy specimens should also be sliced at approximately 10 mm
intervals and examined by eye and palpation to identify any additional abnormalities. These should be
described and sampled.
• Additional representative sampling of the nipple–areolar complex can be performed to assess the presence
of mammary Paget’s disease.
• Additional sampling of quadrants can be performed if resources permit as these can identify occult
extensive disease.
PATHOLOGICAL EXAMINATION OF LYMPH NODES
Resected lymph nodes, usually axillary and occasionally internal mammary, should be submitted for
pathology examination for those patients undergoing surgery for invasive breast carcinoma. These
specimens may take the form of axillary clearance specimens, lymph node samples or sentinel lymph node
biopsies.
Specimen handling: individual lymph nodes (including sentinel nodes)
• designated individual lymph node specimens should be identified separately from the breast sample and
placed in clearly labelled specimen containers for routine fixation.
Tissue blocks
• each lymph node identified should be examined and blocked independently for histological examination
• the methodology used should provide the highest chance of finding metastatic disease by conventional
microscopic examination of haematoxylin and eosin (H&E) stained tissue sections
• a representative complete section of any grossly involved lymph node is adequate
• lymph nodes greater than 5 mm in maximum size should be sliced at intervals of approximately 3 mm or
less perpendicular to the long axis; this is an effective and simpler alternative to serial sectioning to detect
small metastatic deposits in lymph nodes
• all of the tissue blocks prepared should be embedded and examined histologically; for larger lymph nodes,
this may necessitate examination as more than one paraffin block.
• lymph nodes less than 5 mm should, ideally, be bisected and blocked; alternatively, lymph nodes 5 mm or
less can be blocked in their entirety
• examination of levels is not routinely necessary but may be performed if small groups of worrisome cells are
identified, particularly if parenchymal in site.
Pathological examination should be performed on all lymph nodes received, and the report should state the
total number of lymph nodes and the total number containing metastasis.
Specimen handling: axillary clearance with or without mastectomy
• axillary clearance specimens should be placed in clearly labelled containers for routine fixation.
Macroscopic examination
• axillary contents received with mastectomy or biopsy specimens should be examined carefully to maximise
lymph node yield. This is usually achieved by manual dissection of fixed axillary tissue with careful
examination by inspection and palpation. The yield of lymph nodes may be high in such samples. The use of
clearing agents or Bouin’s solution may increase lymph node yield. However, this is time consuming and
expensive and is not
regarded as essential.
• the axillary contents can be divided into three levels if the surgeon has marked the specimen appropriately.
The apical lymph node should be separately identified, if identified surgically.
Tissue blocks
a. Minimum standard method
– every lymph node identified should be examined histologically
– the method should ensure that the total number of lymph nodes should be assessable; this necessitates a
minimum examination of at least one slice of tissue from each node – this minimum standard allows
examination of multiple lymph nodes as composite blocks.
b. Ideal methodology
– the recommended methodology is as described above for lymph node
sample specimens.
Additional techniques for the assessment of lymph nodes for metastatic disease
These include sectioning at multiple levels, use of immunocytochemistry and molecular technology. These
tests may increase the frequency of detection of micrometastatic disease, but at present the significance of
such phenomena is uncertain. The significant additional resources required for such detailed lymph node
examination cannot be justified as routine practice at present.
Should local interest or resources permit, the following could be considered (but is not part of routine
practice):
• Immunocytochemical tests are an adjunct to conventional histology and can facilitate identification of
micrometastatic disease through direct labelling of the tumour cell population, thus enhancing visualisation of
small foci. They may be used for determination of cases where a few worrisome cells are seen on routine
H&E stained sections. However, these isolated tumour cells are now generally believed to be of limited
prognostic significance.
The frequency of detection of micrometastatic disease is also increased through examination of a greater
proportion of the lymph node volume; methods can therefore aim to increase the area fraction of lymph nodes
examined. Methodology includes serial sectioning in some form. The majority of research studies to date
of levels examined beyond this will increase detection but will reduce practicality and significantly increase
costs. As noted earlier in this section, block preparation techniques can provide an effective alternative to
serial sectioning to increase detection of small (< 2 mm) metastatic deposits.
Frozen section examination of lymph nodes for metastatic carcinoma has a high risk of false negative (and
also false positive) classification. For this reason, use of intraoperative frozen sections to examine axillary
lymph nodes should be restricted to research trials and cannot be recommended for routine practice.
MINIMUM DATASET FOR BREAST CANCER HISTOPATHOLOGY
The MVCN strongly recommends that all network pathologists reporting on breast cancer use the
NHSBSP reporting form or similar. This should be for both symptomatic and screen-detected lesions.
The RCPath minimum dataset should be available to the MDT on all breast cancers when cancer
patients are discussed after surgery to make appropriate and timely decisions regarding further
surgery or adjuvant therapy. Although this minimum dataset does not include HER2 receptor status,
it is recommended that it is also included.
The reasons for defining a consistent dataset for reporting breast cancers include:
• the recognition that certain histopathological features of both in situ and invasive carcinoma are directly
related to clinical outcome and may therefore be important in deciding the most appropriate treatment,
including extent of surgery and use of and choice of adjuvant therapy
• using histopathological features to monitor breast screening programmes, the success of which is reflected
by more favourable prognostic features of the cancers detected
• the identification by cancer registries of changing patterns of disease.
The dataset has been approved by The Royal College of Pathologists, the NHSBSP, the European
Commission Working Group for Breast Screening Pathology, the British Association of Surgical Oncologists,
the British Breast Group and the United Kingdom Association of Cancer Registries.
BREAST CANCER HISTOPATHOLOGY MINIMUM DATASET REPORT
Surname Forenames Date of birth
Sex Hospital number NHS number
Date of reporting Report number
Side * Right * Left
Specimen type * Localisation biopsy * Open biopsy
* Wide local excision * Segmental excision
* Mastectomy * Wide bore needle biopsy
Specimen weight ……………………. g
Axillary procedure * No lymph node procedure * Sentinel node biopsy
* Axillary node sample * Axillary node clearance
In situ carcinoma * Not present
* Ductal carcinoma in situ
DCIS grade * High * Intermediate * Low * Not assessable
DCIS growth pattern(s) * Solid * Cribriform * Micropapillary * Papillary
* Apocrine * Flat * Other (please specify) ………………………..
Size .................. mm (DCIS only)
* Lobular carcinoma in situ
* Paget’s disease
Microinvasion * Not present * Present
Invasive carcinoma * Not present
Size Invasive tumour: .................... mm (largest dimension of dominant invasive tumour focus)
Whole size of tumour: .................... mm (invasive plus surrounding DCIS if DCIS extends > 1 mm beyond
invasive)
Type * No special type (ductal NST)
* Pure special type (90% purity, specify components present below)
* Mixed tumour type (50–90% special type component, specify components present below)
* Other malignant tumour (please specify) ………………………
Specify type component(s) present for pure special type and mixed tumour types:
* Tubular/cribriform * Lobular * Mucinous * Medullary like * Ductal/no special type
* Other (please specify) ..............................
Invasive grade * 1 * 2 * 3 * Not assessable
Tumour extent * Localised * Multiple invasive foci
Vascular invasion * Not seen * Present * Possible
Axillary nodes present: * No * Yes Total number ..........................
Number positive ..........................
For single node positivity, specify * Metastasis (> 2 mm)
Other nodes present * No * Yes Total number .......................... Number positive ..........................
Site of other nodes ..............................................................................
Excision margins (for DCIS or invasive carcinoma)
* Not assessable * Reaches relevant margin * Does not reach relevant margin
Closest relevant margin ………………. mm
Oestrogen receptor status * Positive * Negative ……… Quick (Allred) score
* Not performed
NHSBSP HISTOPATHOLOGY REPORTING FORM
The aim is to focus on diagnostic criteria for including lesions in the
various categories and therefore to help to achieve maximum uniformity of reporting.
It is not necessary to use the form as it appears in this document. It may be useful to undertake local
modifications, particularly if the form is also to function as the definitive histopathology report that will be
entered into the patient’s notes and laboratory records. Alternatively, adaptations of the NHSBSP
histopathology reporting form or the RCPath minimum dataset report can be used. Reporting forms can be
downloaded from the NHS Cancer Screening Programmes website (www.cancerscreening. nhs.uk).
NHSBSP HISTOPATHOLOGY REPORTING FORM
Surname Forenames Date of birth
Screening number Hospital number NHS number
Pathologist Laboratory
Date of reporting Report number
Side * Right * Left
Specimen radiograph seen * Yes * No
Mammographic abnormality present in specimen * Yes * No * Unsure
Histological calcification * Absent * Benign * Malignant * Both
Specimen type * Localisation biopsy * Open biopsy
* Wide local excision * Segmental excision
* Mastectomy
Specimen weight .................... g
Axillary procedure * No lymph node procedure * Sentinel node biopsy
* Axillary node sample * Axillary node clearance
Benign lesion present * Yes * No Malignant lesion present * Yes * No
Benign lesion
* Complex sclerosing lesion/radial scar * Fibroadenoma * Multiple papilloma
* Periductal mastitis/duct ectasia * Fibrocystic change * Solitary papilloma
* Sclerosing adenosis * Solitary cyst * Columnar cell change
* Other (please specify) ..............................................................................
Epithelial proliferation
* Not present * Present without atypia
* Present with atypia (ductal) * Present with atypia (lobular)
Malignant lesion
In situ carcinoma * Not present
* Ductal
DCIS grade * High * Intermediate * Low * Not assessable
DCIS growth pattern(s) * Solid * Cribriform * Micropapillary * Papillary
* Apocrine * Flat * Other (please specify) ....................
Size .................... mm (ductal only)
* Lobular
* Paget’s disease
Microinvasion * Not present * Present
Invasive carcinoma * Not present
Size Invasive tumour size .................... mm (largest dimension of dominant invasive
tumour focus)
Whole tumour size .................... mm (invasive plus surrounding DCIS if DCIS
extends > 1 mm beyond invasive)
Type * No special type (ductal NST)
* Pure special type (90% purity, specify components present below)
* Mixed tumour type (50–90% special type component, specify components present below)
* Other malignant tumour (please specify) ………………………
Specify type component(s) present for pure special type and mixed tumour types:
* Tubular/cribriform * Lobular * Mucinous * Medullary like * Ductal/no special type
* Other (please specify) ..............................
Invasive grade * 1 * 2 * 3 * Not assessable
Tumour extent * Localised * Multiple invasive foci
Vascular invasion * Not seen * Present * Possible
Axillary nodes present: * No * Yes Total number .......................... Number positive ..........................
For single node positivity, specify * Metastasis (> 2 mm)
* Micrometastasis
Other nodes present * No * Yes Total number .......................... Number positive ..........................
Site of other nodes ..............................................................................
Excision margins (for DCIS or invasive carcinoma)
* Not assessable * Reaches relevant margin * Does not reach relevant margin
Closest relevant margin .................... mm
Oestrogen receptor status * Positive * Negative ……… Quick (Allred) score
* Not performed
Optional additional fields
Progesterone receptor status * Positive * Negative ……… Quick (Allred) score
* Not performed
HER 2 status * Positive * Negative ……… Score
* Not performed
Comments/additional information
Final histological diagnosis * Normal * Benign * Malignant
London and South East
Sarcoma Network
London and South East Sarcoma Network
Shared Care Pathway for Soft Tissue Sarcomas Presenting to Site Specialised MDTs
Breast sarcomas
Background
This guidance is to provide direction for the management of patients with sarcomas that may present through breast
cancer services and to define the relationship that should exist with the specialist sarcoma MDT. This guidance refers to
the care of patients in the London and South East Sarcoma Network and therefore recognises that specialist services for
soft tissue sarcomas are provided by The London Sarcoma Service provided through joint working of UCLH and RNOH.
Sarcomas arising in the breast are uncommon. A variety of histiotypes are recognised, often presenting as a breast
lump. Nodal involvement occurs infrequently. Cutaneous angiosarcomas are well-recognised as a complication of
previous treatment for breast cancer. The breast is an occasional site of metastasis from sarcoma, particularly
rhabdomyosarcomas. Phyllodes tumours are fibroepithelial tumours which may be benign or malignant and are
generally managed by surgery alone.
Principals
This guidance is being developed in accordance with the relevant measures in the Manual for Cancer Services:
Sarcoma Measures and the Manual for Cancer Services: Breast Measures. They are also written in accordance with the
LSESN referral guidelines (see www.lsesn.nhs.uk) and the LSESN Patient Management Policy.
1) Notification
All sarcoma patients presenting to a local Breast MDT should be notified to the Sarcoma MDT nominated in the local
network Breast cancer operational policy.
2) Review by Sarcoma MDT
a) Pathology
All breast sarcomas will have pathology review undertaken by the nominated specialist sarcoma pathology
service (for details see MDT operational policies).
b) Management
Management of all new soft tissue sarcomas will be referred to the sarcoma MDT. Early referral from the time of
suspicion or biopsy is recommended.
It is not mandatory for phyllodes tumours to be referred to the sarcoma MDT unless there is frank sarcomatous
change or overgrowth.
Radiation induced sarcoma should be managed in a sarcoma centre.
3) Site of Definitive Treatment
Discussion between MDT’s will take place to determine the appropriate hospital for definitive excision. Initial surgical
treatment, may be undertaken by the local breast oncology team. It is preferred that complex surgery and second
operations take place at a sarcoma centre. Discussion is recommended prior to such procedures. Chemotherapy and
radiotherapy will be undertaken by designated practitioners as agreed by the SAG.
4) Recurrence
All recurrent breast sarcomas will be discussed and reviewed by the sarcoma MDT.
Presentation
Diagnosis
Treatment
Follow up
Role and Responsibility
Specialist Breast MDT/Clinic
Sarcoma MDT/Clinic
Assess new cases of suspected
breast cancer
Notify Sarcoma MDT of all new cases
of breast sarcoma
Refer all cases of breast sarcoma for
Review pathology of all new cases
pathology review.
of breast sarcoma
Refer all new cases of breast
Clinical review of all new cases
sarcoma for review by sarcoma MDT
Initial Surgery
Complex surgery and second
operations in conjunction with
centre breast MDT.
All chemotherapy
All radiotherapy
Follow up according to agreed
guidelines of selected patients agreed
by MDT’s
Follow up in accordance with
sarcoma follow up guidelines of all
patients treated by the sarcoma
MDT
Pathway Summary:
GP Referral
(to Breast MDT)
Breast Sarcoma suspected by Breast MDT
on basis of clinical, imaging and/or pathological criteria (imaging and biopsy performed by Breast MDT)
LSS MDT Coordinator Contact details:
Ucl-tr.LondonSarcomaService:nhs.net
Tel: 020 3447 4821
Refer to the London Sarcoma Service
All histology reviewed
by Specialist Sarcoma
Pathologist
A&E Referral
(to Breast MDT)
Discuss at Diagnostic MDT (LSS)
- Pathology review
- Agree management plan
Patients under 24 will also be referred
to the teenage and young adult or
paediatric MDTs as appropriate
See patient in clinic (LSS)
Primary Surgery
Either: Perform at Sarcoma Centre by core member of Sarcoma MDT (LSS) or
Liaise with referring local Breast MDT for site-specific surgery under referring MDT
Further pathology review
by Specialist Sarcoma
Pathologist if required
Primary Chemotherapy and/or Radiotherapy
Either: Treatment at Sarcoma Centre (LLS) or
Liaise with local Breast MDT for local treatment
Post Treatment MDT (LSS)
- further treatment
or
– follow up
Follow Up at Sarcoma Centre (LSS)
Follow Up at local breast unit
Recurrence
Follow Up according
to agreed Breast MDT
guidelines and
LSESN sarcoma
follow-up guidelines
(for those patients
treated by sarcoma
MDT)