Early and locally advanced breast cancer is treated with curative intent.

Surgery for early breast cancer involves either breast-conserving surgery or mastectomy. Breast conserving surgery followed by radiation therapy is as effective as mastectomy for most patients with early breast cancer.

Patients with invasive breast cancer and a clinically and radiologically negative axilla should generally be offered sentinel node biopsy. Axillary treatment with surgery and/or radiation therapy should be considered for patients with nodal disease.

Oncoplastic breast surgery should be considered where appropriate to ensure the patient has the best possible outcome. Surgery may involve the breast surgeon and plastic surgeon working together because some reconstructions are very complex. It is important that patients are given enough time to consider their reconstructive options. This may require more than one appointment with the treating surgeon. It is the responsibility of the multidisciplinary team to ensure the patient is referred in a timely manner to allow for adequate planning of the surgery.

Breast reconstruction surgery

Mastectomy can be performed with or without immediate breast reconstruction. Patients should be fully informed of their options and offered the option of immediate or delayed reconstructive surgery if appropriate.

Timeframe for starting treatment

• Surgery should occur ideally within five weeks of the decision to treat (for invasive breast cancer).
• If being treated with neoadjuvant chemotherapy, surgery is deferred until four to six weeks after the completion of neoadjuvant chemotherapy, ensuring blood counts have recovered.

Training and experience required of the surgeon

• Breast surgeon (FRACS or equivalent, including membership of BreastSurgANZ) with adequate training and experience in breast cancer surgery and institutional agreed scope of practice within this area
• Plastic surgeon with an interest and expertise in breast reconstructive surgery and who contributes to the Australia Breast Device Registry

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with breast cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have access to:

• appropriate nursing and theatre resources to manage complex surgery
• a breast care nurse
• a multidisciplinary team
• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• specialist pathology expertise
• diagnostic imaging
• in-house access to specialist radiology and nuclear medicine expertise.

If appropriate, goserelin for preventing chemo-induced menopause should begin at least one week prior to chemotherapy.

Neoadjuvant therapy, usually chemotherapy, may be appropriate for an increasing number of breast cancers, which may include tumours where the response to neoadjuvant chemotherapy may direct future therapy (e.g. triple-negative and HER2-positive cancers, locally advanced or inflammatory breast cancers as well as some larger operable breast cancers to down-stage tumours), either to make them operable or to allow breast-conserving therapy. The receptor profile of the breast cancer (ER, PR, HER2) assessed by pathologists on the core biopsy is essential in making decisions about the appropriateness and nature of neoadjuvant therapies.

For early breast cancers following surgery, a further discussion at the MDM will determine the appropriateness and type of systemic therapy. All patients with invasive cancer should be considered for systemic therapy.

Patients with LCIS and atypical hyperplasia should be considered for endocrine therapy (tamoxifen or anastrozole) to reduce future invasive breast cancer risk.

All patients with HER2-positive breast cancers (> 5 mm) should be considered for HER2-directed therapy. All patients with hormone receptor-positive breast cancer should be considered for antihormonal therapy. Endocrine therapy should be administered for five years and sometimes longer in higher risk cases.

A core biopsy is the recommended sample for evaluating receptor profile in breast cancer. The information about receptor profile should be made available to the treating teams including the pathologist evaluating the cancer resection specimen. This information helps to identify cases of discordance where further assessment is required and to reduce unnecessary repeat testing.

For patients who have not had a complete pathological response to neoadjuvant therapy, repeat assessment of receptor profile on the resected breast cancer tissue is required to plan ongoing treatment.

Adjuvant bisphosphonates improve survival and should be considered for selected patients being treated for breast cancer with curative intent.

Timeframes for starting treatment

• Neoadjuvant chemotherapy should begin within four weeks of the decision to treat with neoadjuvant chemotherapy.
• Adjuvant chemotherapy should begin within six weeks of surgery.
• Adjuvant chemotherapy for triple-negative breast and HER2-positive breast cancer should begin within four weeks of surgery.
• Endocrine therapy should begin as soon as appropriate after completing chemotherapy, radiation therapy and/or surgery (and in some cases will begin in the neoadjuvant setting).

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians or Medical Oncology Group of Australia (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer (chemotherapy) nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019b)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access.

Radiation therapy is used to treat early, locally advanced, recurrent and metastatic breast cancer in conjunction with surgery and/or systemic treatments, depending on patient and disease factors.

In most cases, radiation therapy is recommended for patients with early breast cancer after breast-conserving surgery.

Hypofractionated radiation therapy (a three- to four-week course) should be considered for most patients with early breast cancer undergoing breast-conserving therapy.

Radiation therapy following mastectomy should be considered for selected patients.

Partial breast irradiation (including intraoperative radiation therapy or linac-based) can be considered for selected patients with early breast cancer.

Discussion at an MDM is essential.

Timeframe for starting treatment

• For patients who do not have adjuvant chemotherapy, radiation therapy should begin within eight weeks of surgery.
• For patients who have adjuvant chemotherapy, radiation therapy should begin three to four weeks after chemotherapy.

Training and experience required of the appropriate specialists

Radiation oncologist (FRANZCR or equivalent) with adequate training and experience that enables institutional credentialing and agreed scope of practice within this area.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

• linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation treatments delivered
• a treatment planning system
• trained medical physicists, radiation therapists and nurses with radiation therapy experience
• coordination for combined therapy with systemic therapy, especially where facilities are not co-located
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system.

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

Assess the patient’s response to all treatments using clinical outcome measures and patient-reported measures.

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

• assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
• access to expert health professionals with specific knowledge about the psychosocial needs of breast cancer patients
• potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
• alteration of cognitive functioning in patients treated with chemotherapy and radiation therapy, which requires strategies such as maintaining written notes or a diary and repetition of information
• loss of fertility, sexual dysfunction or other symptoms associated with treatment or surgically or chemically induced menopause, which requires sensitive discussion and possible referral to a clinician skilled in this area
• general healthcare issues (e.g. smoking cessation and sleep disturbance), which can be referred to a general practitioner
• decline in mobility or functional status as a result of treatment
• management of physical symptoms such as pain, arthralgia and fatigue
• early management for acute pain postoperatively to avoid chronic pain
• side effects of chemotherapy such as neuropathy, cardiac dysfunction, nausea and vomiting; managing these side effects is important for improving quality of life
• managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications – referral to a pharmacist may be required
• menopause symptoms, which may require referral to a menopause clinic
• upper limb problems following surgery including decreased range of movement, which may delay radiation therapy – referral to a physiotherapist may be required
• upper limb and breast lymphoedema following lymphadenectomy/radiation therapy – this is a potential treatment side effect in patients with breast cancer that 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 (prospective monitoring, particularly for high-risk patients is recommended)
• disfigurement and scarring from appearance-altering treatment (and possible need for a prosthetic), which may require referral to a specialist psychologist, psychiatrist or social worker
• weight changes – this may require referral to a dietitian before, during and after treatment
• bowel dysfunction, gastrointestinal or abdominal symptoms as a result of treatment, which may require support from a dietitian
• coping with hair loss and changes in physical appearance (refer to the Look Good, Feel Better program; see ’Resource List’ and/or consider scalp cooling)
• assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

• financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
• advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
• legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

Breast Cancer Network Australia’s helpline (1800 500 258) and website can assist with information and support services.

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

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these important aspects of treatment:

• discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
• providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
• encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
• offering advice to patients and carers on the benefits of and how to access support
• initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

• the general practitioner’s role in symptom management, supportive care and referral to local services
• using a chronic disease management plan and mental health care management plan
• how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.

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