Diagnosis

• Assess the patient’s individual preference for the level and type of information
• Assess metastasis: plain radiography, ultrasound, computed tomography (CT) scans and magnetic resonance imaging (MRI)
• Bones of the axial skeleton using bone windows on a CT scan or MRI or bone scintigraphy, fractures of proximal bones by plain radiography or bone scintigraphy
• PET-CT only if other imaging suspicious but not diagnostic

Investigation

• Patients with tumours of known oestrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status whose disease recurs should not have a further biopsy just to reassess status, only assess if not determined at original presentation

Management

Hormone Therapy

• Offer endocrine therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer
  • Aromatase inhibitor (e.g. Letrozole) either non-steroidal or steroidal, if post-menopausal and no prior history of endocrine therapy, or previously treated with tamoxifen
  • Tamoxifen and ovarian suppression as first-line treatment to premenopausal and perimenopausal women not previously treated with tamoxifen
  • Ovarian suppression to premenopausal and perimenopausal women who have previously been treated with tamoxifen and then experience disease progression
  • Offer tamoxifen as first-line treatment to men with ER-positive advanced breast cancer

Chemotherapy

• Chemotherapy first-line for patients with ER positive advanced breast cancer whose disease is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement, and endocrine therapy following the completion of chemotherapy
• On disease progression, offer systemic sequential therapy to the majority of patients with advanced breast cancer who have decided to be treated with chemotherapy
• Consider using combination chemotherapy to treat patients with advanced breast cancer for whom a greater probability of response is important
• For patients with advanced breast cancer who are not suitable for anthracyclines, systemic chemotherapy should be offered in the following sequence:
  • first line: single-agent docetaxel
  • second line: single-agent vinorelbine or capecitabine
  • third line: single-agent capecitabine or vinorelbine
• Biologics: Trastuzumab for advanced breast cancer, discontinue treatment with trastuzumab at the time of disease progression outside the central nervous system. Do not discontinue trastuzumab if disease progression is within the central nervous system alone

Managing Complications

• Lymphoedema: Exercise no evidence for impact to lymphoedema, but may improve QoL; Treat any underlying condition; Offer complex decongestive therapy (CDT) as the first stage of lymphoedema management; Multilayer lymphoedema bandaging (MLLB) for volume reduction, providing patients with lymphoedema with at least two suitable compression garments
• Fatigue: Assess, offer clear written information and access to exercise program
• Uncontrolled disease: MDT, wound care, palliative care
• Bone metastasis: Bisphosphonates to reduce events and pain, decision locally; External beam radiotherapy in a single fraction of 8Gy to treat patients with bone metastases and pain
• Brain metastasis: Offer surgery followed by whole brain radiotherapy to patients who have a single or small number of potentially resectable brain metastases, active rehabilitation and palliation

NICE Source: CG81 Advanced breast cancer: diagnosis and treatment. Summary compiled by Dr D P Sheppard MBBS.