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.