Patients with breast cancer should be included in decisions on the management of their disease as outlined in the NICE quality standard, says Dr Adrian Harnett

Breast cancer is the commonest cancer in women in the UK accounting for 46,000 new cases per year.1 It is responsible for more than one in six of all cancer deaths in women and is second only to lung cancer.2 Although the incidence of breast cancer is increasing, mortality from the disease is falling.3 This improved mortality can be attributed to many factors including:

  • the use of adjuvant treatments:
    • hormonal therapy
    • chemotherapy
    • biological treatments
    • radiotherapy
  • breast screening
  • early detection and therefore earlier stage disease
  • better management as a result of multidisciplinary team (MDT) working.

Reducing recurrence of breast cancer

Some patients with a history of breast cancer will develop recurrent disease: approximately 35% of women will develop distant metastases;4 hormone-receptor-negative disease recurs predominantly within 5 years while hormone-receptor-positive disease can relapse many years later. New treatments and better understanding of tumour biology have resulted in many patients surviving for longer with metastatic disease.4

An overview on the impact of chemotherapy and hormonal therapy on recurrence of breast cancer and 15-year survival was published in 2005,5 and an update on adjuvant chemotherapy has recently been published by the Early Breast Cancer Trialists’ Collaborative Group.6 Trastuzumab was the first biological therapy to be used widely in breast cancer, firstly in treatment of advanced disease and then as adjuvant treatment,7-5 and has now become standard therapy in human epidermal growth factor 2 (HER2) receptor-positive disease.

Radiotherapy after breast-conserving surgery halves the rate of recurrence and even reduces mortality from breast cancer by about one-sixth.10


Development of the quality standard

The NICE quality standard for breast cancer, published in 2011, sets out the services needed to provide high-quality care across the whole care pathway.11 It is based on previously published national guidelines:

  • NICE Clinical Guideline 80 on early and locally advanced breast cancer (includes large tumours over 5 cm and inflammatory breast cancer)12
  • NICE Clinical Guideline 81 on advanced breast cancer (recurrent, metastatic, and most inoperable breast cancers at presentation)13
  • NICE Clinical Guideline 27 on referral for suspected cancer14
  • SIGN 84 on the management of breast cancer in women.15

A total of 13 quality statements were developed for breast cancer (see Table 1), which cover the following areas from pre-diagnosis through to palliative care:11

  • Referral
  • Clinical assessment
  • Breast-conserving surgery
  • Mastectomy
  • Pathology
  • Management
  • Staging
  • Adjuvant therapy planning
  • Clinical follow up
  • Follow-up imaging
  • MDT
  • Key worker
  • Brain metastases.
Table 1: NICE quality standard for breast cancer11
No. Quality Statements
1 People presenting with symptoms that suggest breast cancer are referred to a unit that performs diagnostic procedures in accordance with NHS Breast Screening Programme guidance.
2 People with early invasive breast cancer are offered a pre-treatment ultrasound evaluation of the axilla and, if abnormal lymph nodes are identified, ultrasound-guided needle biopsy (fine needle aspiration or core). Those with no evidence of lymph node involvement on needle biopsy are offered sentinel lymph node biopsy when axillary surgery is performed.
3 People with early breast cancer undergoing breast-conserving surgery, which may include the use of oncoplastic techniques, have an operation that both minimises local recurrence and achieves a good aesthetic outcome.
4 People with early breast cancer who are to undergo mastectomy have the options of immediate and planned delayed breast reconstruction discussed with them.
5 People with newly diagnosed invasive breast cancer and those with recurrent disease (if clinically appropriate) have the ER and HER2 status of the tumour assessed and the results made available within 2 weeks to allow planning of systemic treatment by the multidisciplinary team.
6 People with early invasive breast cancer, irrespective of age, are offered surgery, radiotherapy, and appropriate systemic therapy, unless significant co-morbidity precludes it.
7 People with early invasive breast cancer do not undergo staging investigations for distant metastatic disease in the absence of symptoms.
8 People with early invasive breast cancer are involved in decisions about adjuvant therapy after surgery, which are based on an assessment of the prognostic and predictive factors, and the potential benefits and side-effects.
9 People having treatment for breast cancer are offered personalised information and support, including a written follow-up care plan and details of how to contact a named healthcare professional.
10 Women treated for early breast cancer have annual mammography for 5 years after treatment. After 5 years, women who are 50 or older receive breast screening according to the NHS Breast Screening Programme timescales, whereas women younger than 50 continue to have annual mammography until they enter the routine NHS Breast Screening Programme.
11 People who develop local recurrence, regional recurrence, and/or distant metastatic disease have their treatment and care discussed by the multidisciplinary team.
12 People with recurrent or advanced breast cancer have access to a 'key worker´, who is a clinical nurse specialist whose role is to provide continuity of care and support, offer referral to psychological services if required, and liaise with other healthcare professionals, including the GP and specialist palliative care services.
13 People who have a single or small number of potentially resectable brain metastases, a good performance status and who have no (or minimal) other sites of metastatic disease are referred to a neuroscience brain and other rare CNS tumours multidisciplinary team.
ER=oestrogen receptor; HER2=human epidermal growth receptor 2; CNS=central nervous system National Institute for Health and Care Excellence website. Breast cancer quality standard. Reproduced with kind permission. Available at: www.nice.org.uk/guidance/qualitystandards/breastcancer/home.jsp (accessed 27 March 2012).

Referral—quality statement 1

Asymptomatic breast cancer can be detected by mammography through the breast-screening service. The breast-screening programme is a detailed and high-quality service16 and as a result high standards have been shown to be in place in screening centres. These high standards should be replicated in all symptomatic clinics (i.e. those clinics for patients presenting with symptoms such as a breast lump, which may be due to breast cancer), not all of which are screening centres.

Assessment—quality statement 2

Staging the axilla is important in obtaining both prognostic information and achieving locoregional control. Additionally, staging can help to guide adjuvant treatment. Historically, axillary surgery was often either not performed or an inadequate sample taken, with fewer than four lymph nodes removed. This procedure was superseded by axillary clearance, which provided prognostic information and locoregional control, but at the expense of morbidity—this is particularly difficult to bear if there is no evidence of any nodal involvement. Sentinel lymph node biopsy has therefore become the preferred technique in staging the axilla.1 If abnormal lymph nodes are observed in a patient, preoperative assessment of the axilla by ultrasound and biopsy allows the most appropriate axillary surgery to be performed and reduces the need for reoperation if a positive sentinel node is found.

Breast surgery—quality statements 3 and 4

Breast conservation and post-operative radiotherapy should be performed in preference to mastectomy, irrespective of the patient’s age. These techniques are increasingly used alongside oncoplastic techniques to achieve better cosmesis, but this should never be at the expense of increased local recurrence. Similarly, patients undergoing a mastectomy should be given the choice of whether they have breast reconstruction, and if so when: immediate or delayed.

Decision making—quality statements 5, 6, 8, and 11

Tumour biology defines appropriate treatment. Oestrogen-receptor and HER2 status is more reliant on the core biopsy and so should be available for treatment decisions when needed and without delay for discussion at the multidisciplinary meeting. This may guide neoadjuvant (or primary systemic therapy) and adjuvant treatment or treatment of advanced and metastatic disease. The potential benefits of chemotherapy and hormonal therapy should be discussed with patients depending on how involved they wish to be, including sharing predictions from tools (for example, see www.adjuvantonline.com/index.jsp).

Patients should be fully included in decisions about their treatment; for example, breast surgery should not be avoided in favour of hormone treatment just because of age. The care of patients with recurrent and metastatic disease should also be discussed by the MDT, which may involve a separate meeting.

Pre-operative staging—quality statement 7

Staging investigations, which usually include a computed tomography scan (of the chest, abdomen, and pelvis) and bone scan, are often requested, but they are rarely helpful in the absence of symptoms and are a waste of resources.15 They can also increase patient anxiety when abnormalities are detected that cannot be definitively benign, requiring further investigations to ally their fears or a follow-up scan after an interval.

Information, support, and follow up—quality statements 9 and 10

Treatment for breast cancer can be quite protracted: surgery followed by chemotherapy where appropriate, radiotherapy and hormone therapy are frequently necessary, with the possible addition of treatment with trastuzumab for 1 year. When patients have completed the most intense part of their treatment, they may feel particularly vulnerable and even isolated. It is important that a care plan is agreed and that patients have a named contact early on in their management. Some patients may want hospital follow up, while others will prefer early discharge and follow up nearer home and delivered by their GP. Part of that follow up includes annual mammography for 5 years after treatment. Women who are aged less than 50 years should continue to have annual mammography, until they reach the age of 50 years. At this age, women will enter the NHS Breast Screening Programme.12


Recurrent and advanced disease—quality statement 12

Clinical nurse specialists are essential members of the MDT meeting and are valued greatly by patients. However they are employed predominantly in the early breast cancer service and thus surgical management. There are few oncology breast-cancer specialist nurses, and patients with recurrent or advanced disease have therefore been relatively neglected in comparison. Nurse specialists have a key role to play in providing continuity of care and support, and coordinating with other healthcare professionals including psychology and lymphoedema services, GPs, and palliative care.

Brain metastases—quality statement 13

It is not uncommon to see patients who have had previous breast cancer with a solitary site of relapse in the brain (or minimal metastatic disease elsewhere). This occurs more often in HER2-positive breast cancer treated with trastuzumab; the brain appears to be a sanctuary site. Often there is a single or a small number of cerebral metastases (see Figure 1, above) and this is associated with a better prognosis so long as an active programme of management is instituted. A neuroscience brain and other rare central nervous system tumours MDT is rather a mouth full but it is the official title of this specialist team and comprises neuroradiologists, neurosurgeons, and oncologists among others. This team will decide whether to proceed with local treatment including neurosurgical excision or stereotactic radiotherapy, or whether to treat more palliatively with whole brain radiotherapy.

Figure 1: Computed tomography brain scan of brain metastases before and after operation

Pre-operationgraph

Post-operation graph

Conclusion

Primary care has an important role in supporting the patient with breast cancer from diagnosis: occasionally giving advice on breast conservation, mastectomy, or immediate reconstruction; and guiding them with respect to adjuvant treatments and participation in clinical trials.

Primary care may also be the setting of choice for patient follow up and GPs can help give advice to patients on long-term adjuvant treatment who may complain of hot flushes and gynaecological symptoms, and those who develop lymphoedema.


  • Breast cancer units should audit:
    • their local recurrence rates
    • breast conservation and mastectomy rates
    • percentage of:
      • patients with ER and HER2 status available (to allow planning of treatment by multidisciplinary team)
      • patients receiving radiotherapy after breast cancer
      • HER2-positive patients receiving chemotherapy
      • HER2-positive patients receiving trastuzumab.

ER=oestrogen receptor; HER2=human epidermal growth receptor 2

  1. Office for National Statistics. Cancer incidence and mortality in the United Kingdom, 2007–2009. London: ONS, 2012.
    Available at: www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-251462
  2. Cancer Research UK website. Breast cancer—UK mortality statistics. info.cancerresearchuk.org/cancerstats/types/breast/mortality
    (accessed 27 March 2012).
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  5. Early Breast Cancer Trialists' Collaborative Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365 (9472): 1687–1717.
  6. Early Breast Cancer Trialists' Collaborative Group. Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials. Lancet 2012; 379 (9814): 432–444.
  7. Romond E, Perez E, Bryant J et al. Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. N Eng J Med 2005; 353 (16): 1673–1684.
  8. Smith I, Procter M, Gelber R et al. 2-year follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer: a randomised controlled trial. Lancet 2007; 369 (9555): 29–36.
  9. Gianni L, Dafni U, Gelber R et al; Herceptin Adjuvant (HERA) Trial Study Team. Treatment with trastuzumab for 1 year after adjuvant chemotherapy in patients with HER2-positive early breast cancer: a 4-year follow-up of a randomised controlled trial. Lancet Oncol 2011; 12 (3): 236–244.
  10. Early Breast Cancer Trialists' Collaborative Group. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011; 378 (9804): 1707–1716.
  11. National Institute for Health and Care Excellence website. Breast cancer quality standard. www.nice.org.uk/guidance/qualitystandards/breastcancer/home.jsp (accessed 14 March 2012).
  12. National Institute for Health and Care Excellence. Early and locally advanced breast cancer. Clinical Guideline 80. London: NICE, 2009. Available at: www.nice.org.uk/CG80 nhs_accreditation
  13. National Institute for Health and Care Excellence. Advanced breast cancer. Clinical Guideline 81. London: NICE, 2009. Available at: www.nice.org.uk/CG81 nhs_accreditation
  14. National Institute for Health and Care Excellence. Referral for suspected cancer. Clinical Guideline 27. London: NICE, 2005. Available at: www.nice.org.uk/CG27
  15. Scottish Intercollegiate Guidelines Network. Management of breast cancer in women. SIGN 84. Edinburgh: SIGN, 1998. Available at www.sign.ac.uk/pdf/sign84.pdf
  16. NHS Breast Screening Programme. Clinical guidelines for breast cancer screening assessment. Third edition. Sheffield: NHS Cancer Screening Programmes, 2010. G