These are the convincing risk factors for developing breast cancer (Cancer Australia 2018) (those highlighted in bold are modifiable):

• age
• gender (being female)
• significant family history of breast cancer and/or other cancers
• pathogenic variants in cancer predisposition genes including BRCA1, BRCA2, CDH1, PALB2, PTEN, NF1, STK11, TP53, ATM and CHEK2
• DCIS (ductal carcinoma in situ)
• LCIS (lobular carcinoma in situ) also referred to as non-invasive lobular neoplasia
• atypical epithelial proliferative lesions (atypical ductal hyperplasia and atypical lobular hyperplasia)
• previous breast cancer
• high mammographic breast density (must be adjusted for age and body mass index)
• early menarche
• not bearing children
• never having breastfed
• late age at first birth
• late menopause
• maternal exposure to diethylstilboestrol (DES) in utero
• use of combined hormone replacement therapy, particularly for extended periods over many years
• not engaging in adequate physically active
• overweight and obesity (only for postmenopausal women)
• weight gain (postmenopausal)
• alcohol consumption
• exposure of the breast to ionising radiation.

For more information, visit the Cancer Australia breast cancer risk factor website.

Recommendations that may assist in preventing breast cancer include:

• maintaining a healthy weight
• avoiding or limiting alcohol intake to no more than 10 standard drinks a week and no more than four standard drinks on any one day
• getting 30 minutes or more of moderate-intensity (puffing) exercise most days (150–300 minutes per week)
• avoiding or limiting hormone replacement therapy use
• additional prevention strategies in people with increased risk (e.g. gene mutation carriers).

Additional prevention interventions are considered for women at increased risk, including those at moderately increased risk. For example, those at moderately increased risk (1.5–3 times the population risk) may be offered medication to reduce risk, and those at high risk (more than three times the population risk) may be offered medication or risk-reducing surgery.

Everyone should be encouraged to reduce their modifiable risk factors (see section 1.1).

By accurately assessing a woman’s personal breast cancer risk level, health professionals can offer the most appropriate evidence-based prevention and early detection strategies. All women should therefore consider having their individual breast cancer risk assessed. This can be done by women themselves or in primary care. Cancer risk assessment should be repeated when major risk factors change (e.g. new family cancer history, breast biopsy showing atypical hyperplasia or LCIS).

There are a number of validated computerised breast cancer risk assessment tools that estimate a woman’s breast cancer risk based on her individual risk factors:

• iPrevent
• IBIS tool
• CanRisk Web Tool

iPrevent is an Australian tool designed for self-administration by women and collaborative use with clinicians and is the only tool that links the risk assessment directly to the relevant risk management guidelines.

In Australia, absolute lifetime population risk of breast cancer is 12 per cent, but most women are below this risk. Cancer Australia defines levels of breast cancer risk as follows:

• average risk: < 1.5 × population risk
• moderate risk: 1.5–3 × population risk
• high risk: > 3 × population risk (Cancer Australia 2010).

People with or without a personal history of breast cancer at high risk due to their family cancer history should be referred to a familial cancer service for further risk assessment and for possible genetic testing (eviQ 2019a). Consider referring:

• untested adult blood relatives of a person with a known pathogenic variant (mutation) in a breast and/or ovarian cancer predisposition gene (e.g. BRCA1 or BRCA2, TP53, PTEN, STK11, PALB2, CDH1, NF1) or
• people with two first- or second-degree relatives diagnosed with breast or ovarian cancer plus one or more of the following on the same side of the family:
• additional relative(s) with breast or ovarian cancer
• breast cancer diagnosed under age 50 years
• more than one primary breast cancer in the same woman
• breast and ovarian cancer in the same woman
• Jewish ancestry
• breast cancer in a male
• pancreatic cancer
• high-grade (≥ Gleason 7) prostate cancer.

Additionally, people with breast cancer should be referred to a familial cancer service if they meet the following criteria:

• male breast cancer at any age
• breast cancer and Jewish ancestry
• two primary breast cancers in the same person, where the first occurred under age 60 years
• two or more different but associated cancers in the same person at any age (e.g. breast and ovarian cancer)
• breast cancer aged under 40 years or triple-negative breast cancer aged under 50 years
• lobular breast cancer and a family history of lobular breast or diffuse-type gastric cancer
• breast cancer aged under 50 years with limited family structure or knowledge (e.g. adopted)
• breast cancer and a personal or family history suggestive of:
• Peutz-Jegher syndrome (oral pigmentation and/or gastrointestinal polyposis)
• PTEN hamartoma syndrome (macrocephaly, specific mucocutaneous lesions, endometrial or thyroid cancer)
• Li-Fraumeni syndrome (breast cancer < 50 years, adrenocorticocarcinoma, sarcoma, brain tumours).

Referral can also be considered if finding a relevant germline mutation would have high clinical utility (e.g. would alter treatment of the current cancer).

The following signs and symptoms should be investigated:

• a persistent new lump or lumpiness, especially involving only one breast
• a change in the size or shape of a breast
• a change to a nipple, such as crusting, ulceration, redness or inversion
• a nipple discharge that occurs without manual expression
• a change in the skin of a breast such as redness, thickening or dimpling
• axillary mass(es)
• an unusual breast pain that does not go away (Cancer Australia 2020b; Walker et al 2014).

People with symptoms as described above should not attend BreastScreen because they will require diagnostic imaging either publicly or privately.

The types of investigation undertaken by a general practitioner depend on many factors including access to diagnostic tests and medical specialists and the patient’s preferences. General practitioners should refer all patients with a suspicious sign or symptom to a breast assessment clinic.

General practitioner examinations and investigations should include a triple test of three diagnostic components:

• medical history and clinical breast examination
• imaging – mammography and/or ultrasound
• non-excision biopsy – preferably core biopsy (Cancer Australia 2017a; Farshid et al. 2019). Pathologists should expedite such testing as part of routine clinical care. Funding through the Medicare Benefits Schedule is accessible for receptor profile evaluation of screen-detected cancers, including immunohistochemistry for ER, PR and HER2 and, when necessary, in situ hybridisation to assess HER2 gene amplification.

Fine-needle aspiration biopsy does not permit distinction between invasive cancer and in situ malignancy. Evaluation of grade and subtype are not reliable, and cytology is inappropriate for assessing a cancer’s receptor profile (ER, PR, HER2), critical for optimal treatment planning, including suitability of neoadjuvant therapy. Fine-needle aspiration cytology may be considered if the clinical and imaging features suggest a benign process, particularly a cystic lesion. If cytology results are non-diagnostic, atypical, suspicious or malignant, core biopsy is needed.

Based on the best available evidence, the triple test provides the most effective means of excluding breast cancer in patients with breast symptoms. A positive result on any component of the triple test warrants referral for specialist surgical assessment and/or further investigation, irrespective of any other normal test results. This implies that not all three components of the triple test need to be performed to reach the conclusion that appropriate referral is needed. The triple test is positive if any component is indeterminate, suspicious or malignant (Cancer Australia 2017a).

For screen-detected lesions, a 2020 review by Cancer Australia established that core biopsy (including vacuum-assisted core biopsy) is the procedure of choice for assessing most screen-detected breast abnormalities (Cancer Australia 2020c). Fine-needle aspiration in the screening setting is appropriate for simple cysts, some complex cystic lesions, axillary lymph nodes and rare situations where a core biopsy is hazardous or technically difficult.

BreastScreen Australia services take responsibility for screening and investigation of screen-detected lesions, including needle biopsies. After multidisciplinary assessment and review of results, recommendations are made for the next steps in management. The woman and her general practitioner are advised of these recommendations in writing. Surgery and ongoing care are typically not part of the BreastScreen program and must be coordinated by the general practitioner through appropriate surgical referral.

To enable timely treatment planning, including consideration of neoadjuvant therapies, it is preferable that the histologic findings, including the receptor profile results, be available in time for the patient’s first consultation with the treating surgeon. Information could be provided to patients to enable them to make an informed decision on neoadjuvant therapy. See Breast Cancer Trials ‘Neoadjuvant patient decision aid’ brochure.

Any patient with symptoms suspicious of breast cancer can be referred for specialist assessment as first line. If the diagnosis of breast malignancy is confirmed or the results are inconsistent or indeterminate, referral to a BreastSurgANZ member breast surgeon is warranted. See BreastSurgANZ ‘Find a surgeon’ for a directory.

Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.

Referral for suspected or diagnosed breast cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:

• important psychosocial history and relevant medical history
• family history, current symptoms, medications and allergies
• results of current clinical investigations (imaging and pathology reports with ER, PR and HER2 receptor profile)
• results of all prior relevant investigations
• notification if an interpreter service is required.

Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.

If access is via online referral, a lack of a hard copy should not delay referral.

The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.

Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.

The treatment team, after taking a medical history and making a medical examination of the patient, should undertake the following investigations under the guidance of a specialist:

• appropriate breast imaging tests including bilateral mammography and ultrasound (if conventional imaging is insufficient to help guide treatment, consider MRI)
• ultrasound of the axilla (including fine-needle aspiration of nodes if the axillary ultrasound is abnormal)
• breast core biopsy, if not already undertaken (which allows determination of breast cancer receptor profiles [ER, PR, HER2]).

Patients should be assessed for the possibility of a breast cancer predisposition gene and considered for genetic counselling/testing if appropriate. For more information refer to eviQ’s Referral guidelines for breast cancer risk assessment and consideration of genetic testing.

Routine staging with, for example, computed tomography (CT) and bone scan are not recommended for most patients with early breast cancer. For a patient presenting with de novo metastatic disease, see Step 6.

Staging is appropriate for patients with confirmed locally advanced or nodal disease and for any patient with clinical symptoms or clinical suspicion of metastatic disease. PET scan may be the most appropriate modality.

Visit the Cancer Institute New South Wales website for information about understanding the stages of cancer.

Patient performance status is a central factor in cancer care and should be clearly documented in the patient’s medical record.

Performance status should be measured and recorded using an established scale such as the Karnofsky scale or the Eastern Cooperative Oncology Group (ECOG) scale.

People over the age of 70 years should undergo some form of geriatric assessment (COSA 2013; palliAGED 2018). Screening tools can be used to identify those patients in need of a comprehensive geriatric assessment (Decoster et al. 2015). This assessment can be used to help determine life expectancy and treatment tolerance and guide appropriate referral for multidisciplinary intervention that may improve outcomes (Wildiers et al. 2014).

Patients should be encouraged to participate in research or clinical trials where available and appropriate.

For more information visit:

• Cancer Australia website
• Breast Cancer Trials website

The intent of treatment can be defined as one of the following:

• curative
• anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The appropriate clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary/alternative therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment often promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

The aim of treatment for breast cancer and the types of treatment recommended depend on the type, stage and location of the cancer and the patient’s age, health and preferences.

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit:

• http://www.australiancancertrials.gov.au
• Breast Cancer Trials website

The transition from active treatment to post-treatment care is critical to long-term health. In some cases, people will need ongoing, hospital-based care, and in other cases a shared follow-up care arrangement with their general practitioner may be appropriate. This will vary depending on the type and stage of cancer and needs to be planned.

Shared follow-up care involves the joint participation of specialists and general practitioners in the planned delivery of follow-up and survivorship care. A shared care plan is developed that outlines the responsibilities of members of the care team, the follow-up schedule, triggers for review, plans for rapid access into each setting and agreement regarding format, frequency and triggers for communication.

Shared follow-up care for early breast cancer is an innovative model of care that supports holistic follow-up and survivorship care following active treatment (Cancer Australia 2019c).

After completing initial treatment, a designated member of the multidisciplinary team (most commonly nursing or medical staff involved in the patient’s care) should provide the patient with a needs assessment and treatment summary and develop a survivorship care plan in conjunction with the patient. This should include a comprehensive list of issues identified by all members of the multidisciplinary team involved in the patient’s care and by the patient. These documents are key resources for the patient and their healthcare providers and can be used to improve communication and care coordination.

The treatment summary should cover, but is not limited to:

• the diagnostic tests performed and results
• diagnosis including stage, prognostic or severity score
• tumour characteristics
• treatment received (types and dates)
• current toxicities (severity, management and expected outcomes)
• interventions and treatment plans from other health providers
• potential long-term and late effects of treatment
• supportive care services provided
• follow-up schedule
• contact information for key healthcare providers.

Responsibility for follow-up care should be agreed between the lead clinician, the general practitioner, relevant members of the multidisciplinary team and the patient. This is based on guideline recommendations for post-treatment care, as well as the patient’s current and anticipated physical and emotional needs and preferences.

The options for follow-up should encompass the following:

• A follow-up schedule will be planned based on the patient’s individual circumstances.
• Investigations should be determined on a case-by-case basis.
• Most follow-up will involve a history, including updating personal history and enquiry about persistent symptoms that might require investigation to exclude metastatic disease. Family cancer history should be updated.
• If the patient has previously had genetic testing that revealed an unclassified variant in a cancer predisposition gene, the clinician should liaise regularly with the relevant familial cancer service until the variant is classified as benign or pathogenic.
• In the case of a pathogenic variant, the clinician should prompt predictive testing in close blood relatives and recommend referral to a familial cancer service.
• Physical examination, and particularly breast examination and limb circumference measure, should be conducted. Annual mammography (unless the patient underwent a bilateral mastectomy) should be undertaken. In some cases it may be appropriate to also undertake breast ultrasound or MRI.
• Appropriate follow-up does not involve chest x-rays, bone scans, CT scans, positron emission tomography (PET) scans or blood tests unless the cancer has spread or there are symptoms suggesting metastases.
• Toxicity related to treatment should be monitored and managed, including bone health
• and cardiovascular health (Blaes & Konety 2020). There is a significant role for physiotherapy in preventing osteoporosis.
• Premenopausal women who develop amenorrhoea are at risk of rapid bone loss. There is evidence that oral bisphosphonates are effective in reducing bone loss.
• Continue to prompt general good health.

Adherence to ongoing recommended treatment such as endocrine therapy should be reviewed and side effects managed proactively to optimise adherence.

Evidence comparing shared follow-up care and hospital-based care indicates equivalence in outcomes including recurrence rate, cancer survival and quality of life (Cancer Research in Primary Care 2016).

Ongoing communication between healthcare providers involved in care and a clear understanding of roles and responsibilities is key to effective survivorship care.

In particular circumstances, other models of post-treatment care can be safely and effectively provided such as nurse-led models of care (Monterosso et al. 2019). Other models of post-treatment care can be provided in these locations or by these health professionals:

• in a shared care setting
• in a general practice setting
• by non-medical staff
• by allied health or nurses
• in a non-face-to-face setting (e.g. by telehealth).

A designated member of the team should document the agreed survivorship care plan. The survivorship care plan should support wellness and have a strong emphasis on healthy lifestyle changes such as a balanced diet, a non-sedentary lifestyle, weight management and a mix of aerobic and resistance exercise (COSA 2018; Hayes et al. 2019).

This survivorship care plan should also cover, but is not limited to:

• what medical follow-up is required (surveillance for recurrence or secondary and metachronous cancers, screening and assessment for medical and psychosocial effects)
• model of post-treatment care, the health professional providing care and where it will be delivered
• care plans from other health providers to manage the consequences of cancer and cancer treatment
• wellbeing, primary and secondary prevention health recommendations that align with chronic disease management principles
• rehabilitation recommendations
• available support services
• a process for rapid re-entry to specialist medical services for suspected recurrence.

Survivors generally need regular follow-up, often for five or more years after cancer treatment finishes. The survivorship care plan therefore may need to be updated to reflect changes in the patient’s clinical and psychosocial status and needs.

Processes for rapid re-entry to hospital care should be documented and communicated to the patient and relevant stakeholders.

Care in the post-treatment phase is driven by predicted risks (e.g. the risk of recurrence, developing late effects of treatment and psychological issues) as well as individual clinical and supportive care needs. It is important that post-treatment care is based on evidence and is consistent with guidelines. Not all people will require ongoing tests or clinical review and may be discharged to general practice follow-up.

The lead clinician should discuss (and general practitioner reinforce) options for follow-up at the start and end of treatment. It is critical for optimal aftercare that the designated member of the treatment team educates the patient about the symptoms of recurrence.

General practitioners (including nurses) can:

• connect patients to local community services and programs
• manage long-term and late effects
• manage comorbidities
• provide wellbeing information and advice to promote self-management
• screen for cancer and non-cancerous conditions.

Templates and other resources to help with developing treatment summaries and survivorship care plans are available from these organisations:

• Australian Cancer Survivorship Centre
• Cancer Australia – Principles of Cancer Survivorship
• Cancer Australia – Shared cancer follow-up and survivorship care: early breast cancer
• Cancer Council Australia and states and territories
• Clinical Oncology Society of Australia – Model of Survivorship Care
• eviQ – Cancer survivorship: introductory course
• MyCarePlan.org.au
• South Australian Cancer Service – Statewide Survivorship Framework resources
• American Society of Clinical Oncology – guidelines.

Support cancer survivors to participate in research or clinical trials where they are available and appropriate. These might include studies to understand survivors’ issues, to better manage treatment side effects, or to improve models of care and quality of life.

For more information visit:

• Cancer Australia website
• Breast Cancer Trials website

Consider the possibility of metastatic breast cancer if the patient has a symptom that persists over several weeks, tending to get worse rather than better and is otherwise unexplained.

Some cases of metastatic disease will be detected at the same time as presentation with the initial primary breast cancer (‘de novo metastatic disease’).

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Symptoms can often present as bone pain (most common), shortness of breath or cough, weight loss, abdominal symptoms or jaundice.

Other patients may present with symptoms of recurrent disease after a previous cancer diagnosis. Patients can present with symptoms of recurrent disease in the locoregional area, or at distant sites, or both. This may include a breast mass, skin nodules, enlarged lymph nodes or inflammatory cancer symptoms. Some local recurrence is detected at follow-up imaging only.

Some cases of recurrent disease will be detected by routine follow-up in a patient who is asymptomatic.

All cases should undergo investigation (staging scans) to establish the extent of disease and be rebiopsied if possible; biopsies should have receptor status re-evaluated.

Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic or recurrent disease.

Managing recurrent or metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate.

A rebiopsy of accessible sites and re-evaluation of breast cancer receptor profile should be undertaken. Non-bony sites are preferred because processing of bone specimens hinders evaluation of HER2 status.

A complete assessment of the sites of disease including CT of the abdomen and pelvis and of the chest plus bone scans, or PET-CT and blood tumour markers should also be undertaken. Brain CT or MRI may be required. Assessment of organ function and comorbidities are necessary.

From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists and metastatic breast cancer nurses. If a metastatic breast cancer nurse is not available, then a resident breast cancer nurse who cares for early and metastatic breast cancer patients may be included.

Treatment will depend on the location, extent of recurrent disease, previous management and the patient’s preferences and may include all modalities of therapies (surgery, radiation therapy and systemic therapy). Antiresorptive therapy may be warranted if bone metastases are present.

In most cases, a combination of anti-cancer and supportive therapies will provide the most effective overall management of recurrent disease.

Regular assessment of the patient’s response to therapy should be undertaken and the therapy changed if disease progresses or as appropriate.

In patients with hormone receptor-positive breast cancer without rapidly progressing visceral disease, endocrine therapy combined with a CD4/6 inhibitor may be the most appropriate treatment initially with use of chemotherapy when endocrine responsiveness is lost.

Many endocrine therapies are effective in producing anti-tumour responses in metastatic breast cancer. These can often be used in sequence to gain successive responses to treatment. They include:

• ovarian ablation/suppression in premenopausal women
• selective oestrogen receptor modulators such as tamoxifen
• aromatase inhibitors, which block oestrogen production
• pure antioestrogen fulvestrant.

Treatment may focus on disease control or palliation based on the extent of disease, general health or the patient’s preferences and values.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Patients should be encouraged to think and talk about their healthcare values and preferences with family or carers, appoint a substitute decision-maker and consider developing an advance care directive to convey their preferences for future health care in the event they become unable to communicate their wishes (AHMAC 2011).

Refer to section 6.6 ‘More information’ for links to resources.

Refer patients and carers to http://www.advancecareplanning.org.au or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on the patient’s need and potential for benefit, not prognosis.

Pain management intervention may be required. Palliative care services would preferably have access to interventional radiologists and pain services to assist with patients whose pain does not respond to conventional medications.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

The patient, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

These online resources are useful:

• Advance Care Planning Australia
• Care Search
• Dying to Talk
• the Palliative Care resource kit
• Palliative Care Australia (for patients and carers)

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For patients with metastatic breast cancer, participation in clinical trials should be revisited by the multidisciplinary team due to alterations in the patient’s disease such as resistance to current treatment or new trials available.

For more information visit the Cancer Australia website.

If the treatment team does not include a palliative care member, the lead clinician should consider referring the patient to palliative care services, with the general practitioner’s engagement. This may include inpatient palliative unit access (as required).

The multidisciplinary team may consider seeking additional expertise from these professionals:

• clinical psychologist
• clinical nurse specialist or practitioner
• social worker
• palliative medicine specialist
• pain specialist
• pastoral or spiritual carer
• bereavement counsellor
• music therapist
• art therapist
• cultural expert
• Canteen for children of parents with cancer

The team might also recommend that patients access these services:

• home and community-based care
• specialist community palliative care workers
• community nursing.

If the patient does not already have an advance care directive in place, a designated member of the treatment team should encourage them to develop one in collaboration with their family or carer (AHMAC 2011).

It is essential for the treatment team to consider the appropriate place of care, the patient’s preferred place of death and the support needed for the patient, their family and carers.

The treatment team should also ensure that carers and families receive the information, support and guidance about their role according to their needs and wishes (Palliative Care Australia 2018).

The treatment team can refer patients and carers to these resources:

• Palliative Care Australia
• Advance Care Planning Australia or to Advance Care Planning Australia’s National Advisory Service on 1300 208 582.

Clinical trials may help improve palliative care and in managing a patient’s symptoms of advanced cancer (Cancer Council Victoria 2019). The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit the Cancer Australia website. See ’Resource list’ for additional clinical trial databases.

Cancer is the third leading cause of burden of disease for Aboriginal and Torres Strait Islander people. While Australia’s cancer survival rates are among the best in the world, Aboriginal and Torres Strait Islander people continue to experience a different pattern of cancer incidence and significant disparities in cancer outcomes compared with non-Indigenous Australians.

For Aboriginal and Torres Strait Islander people, health and connection to land, culture, community and identity are intrinsically linked. Health encompasses a whole-of-life view and includes a cyclical concept of life–death–life.

The distinct epidemiology of cancer among Aboriginal and Torres Strait Islander people, and unique connection to culture, highlight the need for a specific optimal care pathway for Aboriginal and Torres Strait Islander people with cancer. Ensuring this pathway is culturally safe and supportive is vital to tackling the disparities for Aboriginal and Torres Strait Islander people.

Published in 2018, the Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer provides guidance to health practitioners and service planners on optimal care for Aboriginal and Torres Strait Islander people with cancer across the cancer continuum.

In addition to the key principles underpinning cancer-specific pathways, these are the key concepts that are fundamental to Aboriginal and Torres Strait Islander health:

• providing a holistic approach to health and wellbeing
• providing a culturally appropriate and culturally safe service
• acknowledging the diversity of Aboriginal and Torres Strait Islander peoples
• understanding the social determinants and cultural determinants of health (Cancer Australia 2015).

To view the Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer, visit the Cancer Australia website. To view the consumer resources – Checking for cancer and Cancer, visit the Cancer Australia website.

For people from culturally diverse backgrounds in Australia, a cancer diagnosis can come with additional complexities, particularly when English proficiency is poor. In many languages there is not a direct translation of the word ‘cancer’, which can make communicating vital information difficult. Perceptions of cancer and related issues can differ greatly in people from culturally diverse backgrounds and this can affect their understanding and decision making after a cancer diagnosis. In addition to different cultural beliefs, when English language is limited there is potential for miscommunication of important information and advice, which can lead to increased stress and anxiety for patients.

A professionally trained interpreter (not a family member or friend) should be made available when communicating with people with limited English proficiency. Navigation of the Australian healthcare system can pose problems for those with a non-Anglo culture, and members of the treatment teams should pay particular attention to supporting these patients.

The Australian Cancer Survivorship Centre has developed a glossary of more than 700 cancer terms in nine different languages. The multilingual glossary has been designed as a resource for professional translators, interpreters and bilingual health professionals working in the cancer field. The glossary is a unique tool that enables language professionals with access to accurate, consistent and culturally appropriate terminology.

Visit the Peter Mac website to see the glossary.

Disability, which can be physical, intellectual or psychological, may have existed before the cancer diagnosis or may be new in onset (occurring due to the cancer treatment or incidentally). Adjusting to life with a disability adds another challenge to cancer care and survivorship.

Several barriers prevent people with disabilities from accessing timely and effective health care (AIHW 2017):

• physical limitations
• competing health needs
• the trauma of undergoing invasive procedures
• potential barriers associated with obtaining informed consent
• failure to provide assistance with communication
• lack of information
• discriminatory attitudes among healthcare staff.

In caring for people with disabilities and a cancer diagnosis, the Australian Institute of Health and Welfare disability flag should be used at the point of admittance to correctly identify and meet the additional requirements of a person with disability. Facilities should actively consider access requirements, and health practitioners should make reasonable adjustments where required.

Patients aged between seven and 65 years who have a permanent or significant disability may be eligible for support or funding through the National Disability Insurance Scheme (National Disability Insurance Agency 2018). More information can be found on the NDIS website.

Patients aged 65 years or older (50 years or older for Aboriginal or Torres Strait Islander people) may be eligible for subsidised support and services through aged care services. An application to determine eligibility can be completed online over the phone. More information can be found at the http://www.myagedcare.gov.au.

‘Talking End of Life’ is a resource that shows how to teach people with intellectual disability about end of life. It is designed for disability support workers but is also helpful for others including families, health professionals and educators.

To view the resource, visit the Talking End of Life website.

Planning and delivering appropriate cancer care for older people can present a number of challenges. This could also be true for frail people or those experiencing comorbidities. Effective communication between oncology and geriatrics departments will help facilitate best practice care, which takes into account physiological age, complex comorbidities, risk of adverse events and drug interactions, as well as the implications of cognitive impairment on suitability of treatment and consent (Steer et al. 2009).

At a national interdisciplinary workshop convened by the Clinical Oncology Society of Australia, it was recommended that people over the age of 70 undergo some form of geriatric assessment, in line with international guidelines (COSA 2013; palliAGED 2018). Screening tools can be used to identify those patients in need of a comprehensive geriatric assessment (Decoster et al. 2015). This assessment can be used to help determine life expectancy and treatment tolerance and guide appropriate referral for multidisciplinary intervention that may improve outcomes (Wildiers et al. 2014).

Frailty is not captured through traditional measures of performance status (e.g. ECOG) and includes assessment in the domains of:

• function
• comorbidity
• presence of geriatric syndromes
• nutrition
• polypharmacy
• cognition
• emotional status
• social supports.

While there is no accepted definition of ‘young’ regarding breast cancer, younger women have been defined in previous guidelines as women aged 40 or younger at breast cancer diagnosis (Poggio et al. 2018). In 2020, it was estimated that 23 per cent of all new cancer cases diagnosed for Australian women aged 20–39 were for breast cancer (Cancer Australia 2020f). Younger women with breast cancer are likely to face different challenges including:

• early menopause
• fertility and sexuality issues
• role functions including partnering, caring for young children, education and carer issues
• self-image.

Compared with older women, these concerns may contribute to higher levels of psychological distress following diagnosis.

Pregnancy-associated breast cancer, defined as breast cancer diagnosed during pregnancy or in the year after a pregnancy, accounts for 7 per cent of breast cancers in young women (Ives 2009), which is around 100 women annually in Australia. These women typically have a higher disease stage and more aggressive tumour features at diagnosis. However, when matched by age and disease stage with other breast cancer cases, there appears to be no survival difference, except in women diagnosed in the postpartum period, who have higher mortality and increased distant recurrence even after accounting for these factors.

There is an increased incidence of pre-term delivery for this group and management by a multidisciplinary team experienced in caring for these patients is recommended, with consideration given to the optimal time and type of delivery.

A multidisciplinary team approach is essential in managing this group. Initial investigation of any breast symptom in a pregnant or lactating woman should be the same as any other woman, to avoid diagnostic delays. The treating team should include health professionals involved in the treatment of breast cancer, the care of pregnancy and psychosocial support. The recommended obstetric and cancer management of a woman presenting with gestational breast cancer will depend on the fetal gestation and disease status at diagnosis.

In 2020, the estimated number of men diagnosed with breast cancer in Australia is 167 (Cancer Australia 2019d). While breast cancer is uncommon in males, it is important for men who find changes in their breasts to see their doctor without delay. Given the low number of diagnoses and the identification of breast cancer in the general community as a ‘female disease’, many men who are diagnosed with breast cancer can feel isolated and unsupported. This has the potential to cause significant psychological distress and may lead to anxiety and depression. Those working in the area should be alert to the increased risk for psychological complications, the impact on body image and the potential for isolation. Peer support may be useful to normalise the feeling and side effects of treatment. All resources should be cognisant of not excluding men because this has the potential to further ostracise an already isolated group.

Breast Cancer Network Australia’s ‘My Journey online tool’ has information specifically designed for men. Early referral for breast cancer will assist with some of the stigma associated with breast cancer in men and ensure men can connect with others after diagnosis.

In general, people from lower socioeconomic groups are at greater risk of poor health, have higher rates of illness, disability and death, and live shorter lives than those from higher socioeconomic groups (AIHW 2016). People experiencing socioeconomic disadvantage are less likely to participate in screening programs, more likely to be obese, less likely to exercise and much more likely to smoke, which are all risk factors for cancer. In 2010–2014 age-standardised cancer incidence rates were higher in the lowest socioeconomic areas compared with the highest socioeconomic areas for all cancers combined (Cancer Australia 2019b).

Socioeconomic status and low health literacy are closely correlated. Therefore, effective communication with patients and carers is particularly important given the prevalence of low health literacy in Australia (estimated at 60 per cent of Australian adults) (ACSQHC 2014).

Consideration should be taken for cancer patients experiencing socioeconomic disadvantage to reduce their risk of being underserved for health care.

A diagnosis of cancer may present additional challenges to people who have pre-existing chronic mental health or psychiatric concerns, resulting in exacerbation of their mental health symptoms. This may include heightened anxiety, worsening depression or thoughts of self-harm.

As poor adjustment and coping can affect treatment decisions, people who are known to have a mental health diagnosis need psychosocial assessment in the oncology setting to formulate a plan for ongoing support throughout treatment.

Psychosocial support can assist with challenges in communicating with health professionals, enhance understanding of the treatment journey, ensure capacity for consent to treatment options and improve compliance with treatment requests. A referral for psychosocial support from a health professional to the psycho-oncology team can ensure these patients are provided with targeted interventions or referrals to community-based services that may mitigate problems associated with the impacts of social isolation that frequently accompany chronic mental ill-health.

Many patients with chronic mental health problems may be well known to external service providers. Psycho-oncology health professionals can form meaningful partnerships with existing service providers to optimise patient care throughout treatment and beyond.

Drug use disorders fall within the area of mental health conditions. People who are opiate dependent may have specific and individual requirements regarding pain management and their own preference for type of opiate prescribed or used.

People who identify as sexually or gender diverse may have unique needs following a cancer diagnosis. Sexually or gender diverse identities include (but are not limited to) people who identify as lesbian, gay, bisexual or transgender, collectively ‘LGBT’. There is no universally agreed upon initialism to describe this community, with other terms such as queer/questioning (Q), intersex (I), asexual (A) and pansexual (P) often included, as well as a plus symbol (+) indicating inclusivity of other identities not explicitly mentioned.

Sexual orientation and gender identity are relevant across the entire spectrum of cancer care, from prevention to survivorship and end-of-life care. LGBT people are less likely to participate in cancer screening, and some segments of the LGBT community exhibit elevated rates of specific cancer risk factors – for example, higher rates of smoking and alcohol use. Regarding treatment, there may be unique factors relevant to LGBT people that may affect decision making. Additionally, the LGBT population experiences higher rates of anxiety, depression and stressful life circumstances, and may be at risk of inferior psychosocial outcomes following a cancer diagnosis. LGBT people are also more likely to be estranged from their families of origin, and for older people, less likely to have adult children who may provide support and care.

Barriers to care for LGBT people include past negative interactions with healthcare systems, experiences or fear of discrimination and harassment in healthcare settings, assumptions of cisgender/heterosexual identity, lack of recognition or exclusion of same-sex partners from care, and a lack of relevant supportive care and information resources.

To provide safe and appropriate care for LGBT people with cancer, healthcare providers should:

• display environmental cues to show an inclusive and safe setting for LGBT patients
• avoid assumptions about the sexual orientation or gender identity of patients and their partners
• facilitate positive disclosure of sexual orientation or gender identity
• include same-sex/gender partners and families of choice in care
• be aware of relevant supportive care and information resources
• provide non-judgemental, patient-centred care.

Supportive care in cancer refers to the following five domains:

• the physical domain, which includes a wide range of physical symptoms that may be acute, relatively short lived or ongoing, requiring continuing interventions or rehabilitation
• the psychological domain, which includes a range of issues related to the patient’s mental health wellbeing and personal relationships
• the social domain, which includes a range of social and practical issues that will affect the patient, carer and family such as the need for emotional support, maintaining social networks and financial concerns
• the information domain, which includes access to information about cancer and its treatment, recovery and survivorship support services and the health system overall
• the spiritual domain, which focuses on the patient’s changing sense of self and challenges to their underlying beliefs and existential concerns (Palliative Care Victoria 2019).

Fitch’s (2000) model of supportive care recognises the variety and level of intervention required at each critical point as well as the need to be specific to the individual patient. The model targets the type and level of intervention required to meet patients’ supportive care needs.

Consider a referral to a psychologist, psychiatrist, pastoral/spiritual care practitioner, social worker, specialist nurse or a relevant community-based program if the patient has these issues:

• displaying emotional cues such as tearfulness, distress that requires specialist intervention, avoidance or withdrawal
• being preoccupied with or dwelling on thoughts about cancer and death
• displaying fears about the treatment process or the changed goals of their treatment
• displaying excessive fears about cancer progression or recurrence
• worrying about loss associated with their daily function, dependence on others and loss of dignity
• becoming isolated from family and friends and withdrawing from company and activities that they previously enjoyed
• feeling hopeless and helpless about the effect that cancer is having on their life and the disruption to their life plans
• struggling to communicate with family and loved ones about the implications of their cancer diagnosis and treatment
• experiencing changes in sexual intimacy, libido and function
• struggling with the diagnosis of metastatic or advanced disease
• having difficulties quitting smoking (refer to Quitline on 13 7848) or with other drug and alcohol use
• having difficulties transitioning to palliative care.

Additional considerations that may arise for the multidisciplinary team include:

• support for the carer – encourage referrals to psychosocial support from a social worker, psychologist or general practitioner
• referral to an exercise physiologist or physiotherapist as a therapeutic approach to prevent and manage psychological health
• referral to wellness-after-cancer programs to provide support, information and offer strategies.

Complementary therapies may be used together with conventional medical treatments to support and enhance quality of life and wellbeing. They do not aim to cure the patient’s cancer. Instead, they are used to help control symptoms such as pain and fatigue (Cancer Council Australia 2019).

The lead clinician or health professional involved in the patient’s care should discuss the patient’s use (or intended use) of complementary therapies not prescribed by the multidisciplinary team to assess safety and efficacy and to identify any potential toxicity or drug interactions.

The lead clinician should seek a comprehensive list of all complementary and alternative medicines being taken and explore the patient’s reason for using these therapies and the evidence base. A transparent and honest discussion that is free from judgement should be encouraged.

While some complementary therapies are supported by strong evidence, others are not. For such therapies, the lead clinician should discuss their potential benefits and use them alongside conventional therapies (NHMRC 2014).

If the patient expresses an interest in using complementary therapies, the lead clinician should consider referring patients to health providers within the multidisciplinary team who have expertise in the field of complementary and alternative therapies (e.g. a clinical pharmacist, dietitian or psychologist) to assist them to reach an informed decision. Costs of such approaches should be part of the discussion with the patient and considered in the context of evidence of benefit.

The lead clinician should assure patients who use complementary therapies that they can still access a multidisciplinary team review and encourage full disclosure about therapies being used.

• See Cancer Australia’s position statement on complementary and alternative therapies
• See the Clinical Oncological Society of Australia’s position statement Use of complementary and alternative medicine by cancer patients

Advance Care Planning Australia

Advance Care Planning Australia provides national advance care planning resources for individuals, families, health professional and service providers. Resources include a national advisory service, information resources, a legal forms hub and education modules.

• Telephone: 1300 208 582
• Website

Australasian Lymphology Association

The Australasian Lymphology Association has a number of key resources to assist people in gaining an understanding of lymphoedema and the treatments available for the condition.

• Telephone: 1300 935 332
• Website

Australian Cancer Survivorship Centre

The Australian Cancer Survivorship Centre has developed information resources and events to help people move from initial treatment to post treatment and beyond, including those receiving maintenance treatments. While they do not provide clinical advice, they connect with a range of providers to enable improved care.

• Telephone: (03) 8559 6220
• Website

Australian Commission on Safety and Quality in Health Care

The Australian Commission on Safety and Quality in Health Care has developed a resource for patients and carers explaining the coordination of care that patients should receive from their health service during cancer treatment. The resource is called What to expect when receiving medication for cancer care.

Beyond Blue

Beyond Blue provides information about depression, anxiety and related disorders, as well as about available treatment and support services.

• Telephone: 1300 22 4636
• Website

Breast Cancer Network Australia

Breast Cancer Network Australia is a consumer organisation providing specific information on breast cancer.

• Telephone: 1800 500 258
• Website

Cancer Australia

Cancer Australia provides information for consumers, carers and their families including printed resources and video content.

• Website

Cancer Council’s Cancer Information and Support Service

Cancer Council 13 11 20 is a confidential telephone support service available to anyone affected by cancer. This service acts as a gateway to evidence-based documented, practical and emotional support available through Cancer Council services and other community organisations. Calls will be answered by a nurse or other oncology professional who can provide information relevant to a patient’s or carer’s situation. Health professionals can also access this service.

• Telephone: 13 11 20 – Monday to Friday, 9.00am to 5.00pm (some states have extended hours)
• Website

Cancer Council’s Cancer Connect

Cancer Connect is a free and confidential telephone peer support service that connects someone who has cancer with a specially trained volunteer who has had a similar cancer experience.

A Connect volunteer can listen with understanding and share their experiences and ways of coping. They can provide practical information, emotional support and hope. Many people newly diagnosed with cancer find this one-to-one support very beneficial.

For more information on Cancer Connect call Cancer Council on 13 11 20.

Canteen

Canteen helps adolescents, young adults and parents to cope with cancer in their family. Canteen offers individual support services, peer support services and a youth cancer service, as well as books, resources and useful links.

• Telephone: 1800 835 932 to talk to a health professional about information and support for young people or 1800 226 833 for other enquiries
• Website

Clinical trial information

For a collection of clinical trials available in Australia see the following sources of information:

• Australian clinical trials
• Australian New Zealand Clinical Trials Registry
• ClinicalTrials.gov

CanEAT pathway

A guide to optimal cancer nutrition for people with cancer, carers and health professionals.

• Education website
• Patient website 

Guides to best cancer care

The short guides help patients, carers and families understand the optimal cancer care that should be provided at each step. They include optimal timeframes within which tests or procedures should be completed, prompt lists to support patients to understand what might happen at each step of their cancer journey and to consider what questions to ask, and provide information to help patients and carers communicate with health professionals.

The guides are located on an interactive web portal, with downloadable PDFs available in multiple languages.

• Website

Look Good, Feel Better

A free national community service program, run by the Cancer Patients Foundation, dedicated to teaching cancer patients how to manage the appearance-related side effects caused by treatment for any type of cancer.

• Telephone: 1800 650 960
• Website

McGrath Foundation

The McGrath Foundation employs breast care nurses who help individuals and their families experiencing breast cancer by providing physical, psychological and emotional support.

• Telephone: (02) 8962 6100
• Website

Quitline

Quitline is a confidential, evidence-based telephone counselling service. Highly trained Quitline counsellors use behaviour change techniques and motivational interviewing over multiple calls to help people plan, make and sustain a quit attempt.

Quitline is a culturally inclusive service for all, and Aboriginal counsellors are also available. Health professionals can refer patients to Quitline online or via fax.

• Telephone: 13 7848
• Website or the relevant website in your state or territory.

Australian Cancer Survivorship Centre

The Australian Cancer Survivorship Centre provides expertise in survivorship care, information, support and education. Its purpose is to support and enable optimal survivorship care.

• Telephone: (03) 8559 6220
• Website

Australian Commission on Safety and Quality in Health Care

The Australian Commission on Safety and Quality in Health Care has developed a guide for clinicians containing evidence-based strategies to support clinicians to understand and fulfil their responsibilities to cancer patients. This guide is particularly relevant to steps 3 to 6 of the optimal care pathway. The guide is titled NSQHS Standards user guide for medication management in cancer care for clinicians.

Cancer Australia

Information for health providers including guidelines, cancer learnings, cancer guides, reports, resources, videos, posters and pamphlets.

• Website

Cancer Council Australia

Information on prevention, research, treatment and support provided by Australia’s peak independent cancer authority.

• Website

CanEAT pathway

A guide to optimal cancer nutrition for people with cancer, carers and health professionals.

• Website
• Website

CounterPart

Peer support for women living with breast or gynaecological cancer. This support service offers high-quality evidence-based educational resources and a drop-in centre.

• Phone: 1300 781 500
• Website

eviQ

A clinical information resource providing health professionals with current evidence-based, peer-maintained, best practice cancer treatment protocols and information relevant to the Australian clinical environment.

• Website

National Health and Medical Research Council

Information on clinical practice guidelines, cancer prevention and treatment.

• Website

We acknowledge the Traditional Owners of Country throughout Australia and their continuing connection to the land, sea and community. We pay our respects to them and their cultures and to Elders past, present and emerging.

This work is available from the Cancer Council website.

First published in September 2015. This edition published in June 2021.

ISBN: 978-1-76096-149-7

Cancer Council Victoria and Department of Health Victoria 2021 Optimal care pathway for people with breast cancer, 2nd edn, Cancer Council Victoria, Melbourne.

Enquiries about this publication can be sent to optimalcare.pathways@cancervic.org.au.

Our thanks to the following health professionals, consumer representatives, stakeholders and organisations consulted in developing this optimal care pathway.

Professor Christobel Saunders (Chair), Surgeon, Royal Perth Hospital, Fiona Stanley Hospital, St John of God Subiaco Hospital; Professor Surgical Oncology, The University of Western Australia; Chair, PathWest Laboratory Medicine

Professor Fran Boyle, Medical Oncologist, Mater Hospital

Dr Adrian Dabscheck, Palliative Care Physician, Western Health

Dr Bianca Devitt, Medical Oncologist, Eastern Health

Miss Gillian Farrell, Plastic Surgeon, Cabrini Health

Professor Gelareh Farshid, Senior Consultant Pathologist; SA Pathology, Royal Adelaide Hospital

Dr Jocelyn Lippey, Surgeon, St Vincent’s Hospital Melbourne and Northern Hospital

Professor Bruce Mann, Surgeon, The Royal Melbourne Hospital, The Royal Women’s Hospital and Peter MacCallum Cancer Centre

Professor Kelly-Anne Phillips, Medical Oncologist, Peter MacCallum Cancer Centre

Ms Kirsten Pilatti, Chief Executive Officer, Breast Cancer Network Australia

Ms Lisa Sheeran, Breast Care Nurse Consultant, Peter MacCallum Cancer Centre

Ms Danielle Spence, Head of Division, Strategy and Support, Cancer Council Victoria

Professor Robert Thomas, Special Advisor on Health, Professorial Fellow, The University of Melbourne

Dr Alison Trainer, Clinical Geneticist, Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital

Dr Yvonne Zissiadis, Radiation Oncologist, Genesis Care

Ms Julia Brancato, Project Coordinator, Optimal Care Pathways, Cancer Council Victoria

Professor Christobel Saunders, Surgeon (Chair), Royal Perth Hospital, Fiona Stanley Hospital, The University of Western Australia

Associate Professor Boon Chua, Radiation Oncologist, Peter MacCallum Cancer Centre

Associate Professor Jacquie Chirgwin, Medical Oncologist, Box Hill Hospital; Director, ANZ Breast Cancer Trials Group

Ms Linda Cicciarelli, Genetic Counsellor, Peter MacCallum Cancer Centre

Dr Adrian Dabscheck, Palliative Care Physician, Western Health

Miss Gillian Farrell, Plastic Surgeon, Cabrini Health

Associate Professor Gelareh Farshid, Pathologist; Clinical Director, BreastScreen SA

Ms Jane Fletcher, Health Psychologist, Cabrini Health; Director, Melbourne Psycho-oncology Service

Ms Coral Keren, consumer representative

Professor Bruce Mann, Surgeon, The Royal Melbourne Hospital, The Royal Women’s Hospital and Peter MacCallum Cancer Centre

Ms Sarah Pratt, Breast Care Nurse, Peter MacCallum Cancer Centre

Professor Kelly-Anne Phillips, Medical Oncologist, Peter MacCallum Cancer Centre

Professor Gary Richardson, Medical Oncologist, Cabrini Health

Dr Liu-Ming Schmidt, Surgeon, Albury Surgical Group

Ms Wanda Stelmach, General and Breast Surgeon; Clinical Program Director, Surgery, Northern Health

Dr Karen Taylor, Senior Specialist Radiation Oncologist, William Buckland Radiotherapy Centre, The Alfred, Cabrini Health

Mr Peter Thomas, General and Breast Surgeon, Wangaratta

Dr John Waugh, Radiologist, Director of Training, Monash BreastScreen

Professor Robert Thomas, Chief Advisor on Cancer, Department of Health and Human Services, Victoria

Advance Care Planning Australia

Allied Health Professions Australia

Australasian Association of Nuclear Medicine Specialists

Australasian Chapter of Palliative Medicine, Royal Australia College of Physicians

Australasian Lymphology Association

Australian and New Zealand Society of Neuroradiology

Australian and New Zealand Society of Palliative Care

Australian Cancer Survivorship Centre

Australian College of Nursing

Australian Medical Association

Australian Society of Medical Imaging and Radiation Therapy

Breast Cancer Network Australia

Breast Screen Victoria

Cancer Nurses Society of Australia

Clinical Oncology Society of Australia

Counterpart

Interventional Radiology Society of Australasia

Medical Oncology Group of Australia

McGrath Foundation

National Breast Cancer Foundation

Oncology Social Workers Australia and New Zealand

Royal Australasian College of Physicians

Royal Australasian College of Surgeons

Royal Australian and New Zealand College of Radiologists

Royal Australian College of General Practitioners

Royal College of Pathologists of Australasia

Alfred Health

Cancer Australia

Cancer Council Victoria, Strategy and Support Division

Cancer Institute New South Wales

Concord Repatriation General Hospital New South Wales

Consumer representative

Department of Health Victoria, Commissioning and System Improvement Division, Cancer Unit

National Cancer Expert Reference Group

Olivia Newton-John Cancer Wellness and Research Centre

St Vincent’s Hospital Melbourne

Other stakeholders consulted to provide feedback include relevant Cancer Council committees and networks, Integrated Cancer Services, Primary Health Networks and several health services.

The multidisciplinary team should include the following members:

• breast surgeon
• medical oncologist
• nurse(s) (with appropriate expertise such as a breast care nurse)
• pathologist
• radiation oncologist
• radiologist.

The multidisciplinary team may include the following members:

• Aboriginal health practitioner, Indigenous liaison officer or remote general practitioner
• care coordinator
• clinical trial nurse/coordinator
• dietitian
• exercise physiologist
• fertility specialist
• general practitioner
• geneticist and/or genetic counsellor
• lymphoedema physiotherapist/specialist
• occupational therapist
• pain specialist
• palliative care specialist
• pharmacist
• physiotherapist
• plastic surgeon
• psychologist
• psychiatrist
• reconstructive surgeon
• social worker
• spiritual/pastoral care.