Diagnostic investigations should be completed within two weeks of the initial specialist consultation.

People with breast cancer should be referred for genetic work-up early in their treatment journey if they fulfil germline testing criteria using CanRisk or the Manchester score, or have a triple-negative breast cancer under 50 years of age. Other factors pertaining to genetic work-up include 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).

Family history-based testing threshold can be assessed using the Manchester score APP.

In some cases certain pathological subtypes of cancer or tumour tests (immunohistochemistry or tumour genetic tests) may suggest an underlying inherited cancer predisposition, especially triple-negative breast cancers.

Genetic testing is sometimes able to identify the cause of cancer in a family and may be used to guide treatment for the affected people.

A familial cancer service assessment can determine if genetic testing is appropriate. Genetic testing is likely to be offered when there is at least a 10 per cent chance of finding a causative ‘gene error’ (pathogenic gene variant; previously called a mutation). Usually testing begins with a variant search in a person who has had cancer (a diagnostic genetic test). If a pathogenic gene variant is identified, variant-specific testing is available to relatives to see if they have or have not inherited the familial gene variant (predictive genetic testing).

Medicare funds some genetic tests via a Medicare Benefits Schedule item number. Depending on the personal and family history, the relevant state health system may fund public sector genetic testing.

Pre-test counselling and informed consent is required before any genetic testing. In some states the treating team can offer ‘mainstream’ diagnostic genetic testing, after which referral is made to a familial cancer service if a pathogenic gene variant is identified. The familial cancer service can provide risk management advice, facilitate family risk notification and arrange predictive genetic testing for the family.

Visit the Centre for Genetics Education website for basic information about cancer in a family.

For detailed information and referral guidelines for breast cancer risk assessment and consideration of genetic testing, read eviQ’s Referral guidelines for breast cancer risk assessment and consideration of genetic testing.

A number of factors should be considered at this stage:

• the patient’s overall condition, life expectancy, decision-making capacity and results from a geriatric assessment if appropriate in those over the age of 70 years
• patient preferences and aims of treatment
• psychosocial screening/evaluation and support
• discussing the multidisciplinary team approach to care with the patient
• ensuring a breast care nurse is part of the multidisciplinary team
• appropriate and timely referral to an MDM
• considering if an interpreter is required
• pregnancy and fertility options, contraception and prevention of chemotherapy-induced menopause
• financial and social aspects
• support with travel and accommodation
• teleconferencing or videoconferencing as required.

Discussion at an MDM is a core component of quality care (ASCO & ESMO 2006). All patients with a new diagnosis of breast cancer should be referred to an MDM for discussion. Ideally, the multidisciplinary team should discuss all newly diagnosed patients with breast cancer prior to surgery or neoadjuvant chemotherapy. Results of all relevant tests and imaging should be available for the MDM. To assist with the burden of demand, sites may streamline and prioritise the MDM discussion using agreed protocols. Patients should be offered a referral to a breast cancer nurse within seven days of a definitive diagnosis.

Patients may be discussed at several time points during their diagnosis and treatment. This can ensure patients are identified who may benefit from neoadjuvant systemic therapy, where surgical decisions are complex and in planning of reconstructive surgery and sequencing of therapies, or for relevant clinical trials.

The multidisciplinary team requires administrative support in developing the agenda for the meeting, for collating patient information and to ensure appropriate expertise around the table to create an effective treatment plan for the patient. The MDM has a chair and multiple lead clinicians. Each patient case will be presented by a lead clinician (usually someone who has seen the patient before the MDM). In public hospital settings, the registrar or clinical fellow may take this role. A member of the team records the outcomes of the discussion and treatment plan in the patient history and ensures these details are communicated to the patient’s general practitioner.

When developing treatment recommendations for each patient, MDM participants ensure:

• the tumour has been adequately staged
• all appropriate treatment modalities are considered
• psychosocial and medical comorbidities that may influence treatment decisions are considered
• the patient’s treatment preferences are known and considered
• clinical trial eligibility, availability and participation are considered
• relevant optimal care pathway timeframes are considered.

The team should consider the patient’s values, beliefs and cultural needs as appropriate to ensure the treatment plan is in line with these. There may be early consideration of post-treatment pathways at this point – for example, shared follow-up care.

MDMs should aim to develop and agree by consensus an individualised treatment plan for each patient discussed. At times when there is a divergence of opinion about a patient’s management or equivalent options, these differing opinions should be discussed with the patient to enable them to make an informed decision. Patients should be given time to discuss treatment options with others before making this decision.

MDM recommendations should be communicated in a timely manner to the patient and referring doctor/general practitioner with formal documentation. Further details regarding MDM requirements can be found via the Victorian cancer multidisciplinary team meeting quality framework.

The multidisciplinary team should be composed of the core disciplines that are integral to providing good care. Team membership should reflect both clinical and supportive care aspects of care. Pathology and radiology expertise are essential.

See ‘About this OCP’ for a list of team members who may be included in the multidisciplinary team for breast cancer.

Core members of the multidisciplinary team are expected to attend most MDMs either in person or remotely via virtual mechanisms. Additional expertise or specialist services may be required for some patients such as breast cancer patients during pregnancy. An Aboriginal and Torres Strait Islander cultural expert should be considered for all patients who identify as Aboriginal or Torres Strait Islander.

The general practitioner who made the referral is responsible for the patient until care is passed to another practitioner who is directly involved in planning the patient’s care.

The general practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, shared follow-up care, post-treatment surveillance, coordination and continuity of care, as well as managing existing health issues and providing information and support to the patient, their family and carer.

A nominated contact person from the multidisciplinary team may be assigned responsibility for coordinating care in this phase. Care coordinators (usually a breast care nurse) are responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase (COSA 2015). The care coordinator may change over the course of the pathway.

The lead clinician is responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.

Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as surgery, systemic therapy and radiation therapy. Team members may include anaesthetists, oncologists, surgeons, haematologists, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool, such as the Malnutrition Screening Tool (MST). The lead clinician may refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving treatment. This should include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy if clinically appropriate.

Evidence indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

A key contact person, ideally a breast care nurse, should be agreed as soon as possible (within seven days is optimal) to support communication and coordination of patient-centred care. Consultations may be via telephone and/or videoconferencing, where appropriate (Cancer Australia 2020e).

For patients with breast cancer, the multidisciplinary team should consider these specific prehabilitation assessments and interventions for treatment-related complications or major side effects:

• conducting a physical and psychological assessment to establish a baseline function level
• identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
• reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions. Some medications, such as anticoagulants, may need to be modified before surgery.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

See Breast Cancer Network Australia’s ‘Physical Preparation & Recovery After Breast Reconstruction’.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Patients need to be advised about and potentially referred for discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

The potential for impaired fertility should be discussed and reinforced at different time points as appropriate throughout the diagnosis, treatment, surveillance and survivorship phases of care. These ongoing discussions will enable the patient and, if applicable, the family to make informed decisions. All discussions should be documented in the patient’s medical record.

See the Cancer Council website for more information.

See Breast Cancer Network Australia’s fertility video for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

• assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
• access to expert health professionals with specific knowledge about the psychosocial needs of breast cancer patients
• for some populations (culturally diverse backgrounds, Aboriginal people and lesbian, transgender and intersex communities) a breast cancer diagnosis comes with additional psychosocial complexities, and discrimination uncertainty may also make these groups less inclined to seek regular medical care – access to expert health professionals with specific knowledge about the psychosocial needs of these groups may be required
• preservation of ovarian function should be discussed before starting treatment – goserelin reduces the risk of chemotherapy-induced menopause and should particularly be discussed before chemotherapy for women with ER-negative breast cancer (for some women with ER-positive breast cancer it may also be appropriate to use goserelin before and during chemotherapy; see Breast Cancer Network Australia’s Fertility-related choices booklet
• management of physical symptoms such as pain and fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019)
• upper limb and breast lymphoedema and cording following lymphadenectomy – this is a potential treatment side effect in people with breast cancer, which has a significant effect on survivor quality of life; referral (preferably preoperatively) to a health professional with accredited lymphoedema management qualifications, offering the full scope of complex lymphoedema therapy, should be encouraged
• limitations in upper limb movement and function, which may affect radiation therapy – referral to a physiotherapist may be required (prospective monitoring, particularly for high-risk patients is recommended)
• weight changes, which can be a significant issue for patients, and may require referral to a dietitian before, during and after treatment
• malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high body mass index [obese patients] may also be malnourished [WHO 2018])
• support for families or carers who are distressed with the patient’s cancer diagnosis
• support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
• specific spiritual needs that may benefit from the involvement of pastoral/spiritual care
• financial and employment issues (such as loss of income and having to deal with travel and accommodation requirements for rural patients and caring arrangements for other family members).

Additionally, palliative care may be required at this stage.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

In discussion with the patient, the lead clinician should undertake the following:

• establish if the patient has a regular or preferred general practitioner and if the patient does not have one, then encourage them to find one
• provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for breast cancer, as well as to relevant websites and support groups as appropriate
• refer the patient to Breast Cancer Network Australia’s ‘My Journey online tool’
• discuss the importance of relatives accessing predictive genetic testing when a pathogenic variant is identified in the patient
• provide a treatment care plan including contact details for the treating team and information on when to call the hospital
• discuss a timeframe for diagnosis and treatment with the patient and carer
• discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
• provide brief advice and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, if clinically appropriate
• recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise and minimal or no alcohol consumption among other considerations
• communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
• where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
• be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
• encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment preferences. Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

Consider appointing one lead clinician at the time of initial diagnosis; however, all treating clinicians have these communication responsibilities:

• involving the general practitioner from the point of diagnosis
• ensuring regular and timely communication with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs and inviting them to participate in MDMs (consider using virtual mechanisms)
• gathering information from the general practitioner including their perspective on the patient’s psychosocial issues and comorbidities and locally available support services
• supporting the role of general practice both during and after treatment
• discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient
• contributing to the development of a chronic disease and mental health care plan as required, particularly to access community supportive care service
• notifying the general practitioner if the patient does not attend appointments.

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.