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.