Clinical Guidelines For The Management Of Breast Cancer

Clinical Guidelines forthe Management ofBreast CancerWest Midlands Expert Advisory Groupfor Breast Cancer

West Midlands Clinical Networksand Clinical SenateCoversheet for Network Expert Advisory Group Agreed DocumentationThis sheet is to accompany all documentation agreed by the West Midlands StrategicClinical Network Expert Advisory Groups. This will assist the Clinical Network to endorse thedocumentation and request implementation.EAG nameBreast Cancer Expert Advisory GroupDocumentTitleClinical guidelines for the management of breast cancerPublisheddateDocumentPurposeDecember 2016AuthorsOriginal Author:Mr Stephen ParkerClinical guidance for the management of Breast cancer to all practitioners,clinicians and health care professionals providing a service to all patientsacross the West Midlands Clinical Network.Modified By:Mrs Abigail TomlinsConsultant Breast SurgeonUniversity Hospitals Coventry & Warwickshire NHS TrustReferencesConsultation These guidelines were originally authored by Stephen Parker andProcesssubsequently modified by Abigail Tomlins for the Coventry, Warwickshire andWorcestershire Breast Group. The West Midlands EAG agreed to adopt theseguidelines as the regional network guidelines. The version history reflectschanges made by the Coventry, Warwickshire and Worcestershire BreastGroup. As the Coventry, Warwickshire and Worcestershire Breast Groupupdate their guidelines, the EAG will discuss whether to adopt the updatedversion.Review Date December 2019(must bewithin threeyears)ApprovalNetwork Clinical DirectorSignatures:Date: ent-of-breast-cancer-v1.doc2

Version History - Coventry, Warwickshire and WorcestershireBreast GroupVersion2010v1.0DDate12 March 20102011v1.0D25 March 20112012 v1.0D29 February 20122013v1.0D5 February 20132014v1.0D23 September 20142015v1.0DOctober 2015Brief Summary of ChangeImmediate breast reconstruction criteriaYoung adult survivorsUpdated follow-up guidelines.The cut off age for mammography has been increasedfrom 35 to 40Addition of a section about the referral process forreconstruction at UHCW.Updated guidance on anterior resection marginsUpdated MRI guidelinesUpdated radiotherapy guidelinesUpdated neoadjuvant chemotherapy guidelinesGuidance on cannulation after sentinel node biopsyTamoxifen and elective surgeryManagement of B3 lesionsUpdated oncoplastic guidelinesRadiotherapy treatment protocolsUse of CT for metastatic screeningMDT discussion of private patientsSkin marking of impalpable lesionsManagement of positive sentinel nodesExtended adjuvant therapyFailed localisation proceduresFollow up protocolMRI in high risk patientsNICE referral guidanceNew TWW formVersion History – West Midlands Clinical NetworkVersion2016 v1Date12th December 2018Brief Summary of ChangeThe EAG adopted in full version 2015v1.0D of theCoventry, Warwickshire and Worcestershire Breast anagement-of-breast-cancer-v1.doc3

IntroductionThese guidelines are for the management of patients with breast cancer across the WestMidlands. A guideline is not a rigid constraint on clinical practice, but a concept of goodpractice against which the needs of the individual patient should be considered. It thereforeremains the responsibility of the individual clinician to interpret the application of theseguidelines, taking into account local service constraints and the needs and wishes of thepatient. It is not intended that these guidelines are applied as rigid clinical protocols.National guidelines exist covering many aspects of breast cancer care. These regionalguidelines have been developed against this background. The following guidelines havebeen reviewed and adapted in the production of this local document: Surgical guidelines for the management of breast cancer. Association of BreastSurgery at BASO. 2009 Early and locally advanced breast cancer. Diagnosis and treatment. NationalInstitute for Clinical Excellence. 2009 Advanced breast cancer. Diagnosis and treatment. National Institute for ClinicalExcellence. 2009 Familial breast cancer. The classification and care of women at risk of familial breastcancer in primary, secondary and tertiary care. National Institute for ClinicalExcellence. 2006 Quality assurance guide lines for surgeons in breast cancer screening. NHSBSPPublication No.20. November 2009 NHSBSP Guidelines for Pathology Reporting in Breast Disease, 2005 Royal College of Pathologists Minimum Dataset for Breast cancer, 2008 Referral for suspected cancer. National Institute for Clinical Excellence. 2005 Oncoplastic breast surgery – a guide to good practice. Association of Breast Surgeryat BASO, the British Association of Plastic, Reconstructive and Aesthetic Surgeonsand the Training Interface Group in Breast Surgery. 2007 National Comprehensive Cancer Network Breast Cancer Guideline, Version 2. 2008 Best practice diagnostic guidelines for patients presenting with breast symptoms.Department of Health, 2010 London Region Quality Assurance Reference Centre Guidance on management ofindeterminate breast lesions. 2012 Oncoplastic Breast Reconstruction. Guidelines for Best Practice. Association ofBreast Surgery and British Association of Plastic Reconstructive and AestheticSurgeons. -breast-cancer-v1.doc4

Acellular dermal matrix assisted breast reconstruction: Joint guidelines from theAssociation of Breast Surgery and the British Association of Plastic, Reconstructionand Aesthetic Surgeons. 2013. Suspected Cancer: Recognition and Referral – NG12, Published June -breast-cancer-v1.doc5

ContentsOrganisation of breast cancer surgical services . 8The multidisciplinary team (MDT) . 8Private patients . 9Young survivors of cancer . 9Assessment and diagnosis. 9Referral guidelines . 9Lumps, lumpiness and change in texture . 10Nipple symptoms . 10Male patients . 10Other symptoms . 10Diagnosis . 11Imaging . 13Axillary ultrasound . 13Metastatic screening . 14Magnetic resonance imaging. 14Family history screening and surveillance protocols . 15Treatment planning and communication . 16Providing information and psychological support . 16Surgery . 16Surgery for invasive breast cancer . 16Breast conserving surgery . 17Indications for breast conserving surgery . 17Skin marking of impalpable lesions . 17Failed localisations . 17Mastectomy. 18Indication for mastectomy. 18Margins of excision . 18Axillary surgery . 19Surgery for Ductal carcinoma in situ . 20Surgery for Paget’s disease . 20Surgery for lobular in situ neoplasia . 21Ambulatory Breast Care Model for breast cancer surgery . 21Exclusion Criteria . 21Drains and Dressings Policy . 21Discharge . 22Information to General Practitioners . 22Breast reconstruction . 22Referral for breast reconstruction at UHCW . 23Therapeutic mammoplasty . 23Pathology . 24Specimen types. 24Diagnostic specimens . 24Therapeutic specimens . 24Specimen examination . 24Macroscopic examination . 25Radiological-pathological correlation . 25Post neo-adjuvant chemotherapy specimens . 25Ductal carcinoma in situ (DCIS). 25Sentinel lymph nodes . 25Use of ancillary techniques . 25Reporting of specimens. 26Minimum dataset for reporting . reast-cancer-v1.doc6

Diagnostic specimens: . 26Screening and symptomatic therapeutic resections: . 26Audit . 27Referral for review or external opinion . 27Adjuvant therapy . 27Adjuvant therapy planning . 28Radiotherapy. 28Radiotherapy after breast conserving surgery . 28Radiotherapy after mastectomy . 28Radiotherapy for DCIS . 29Radiotherapy to nodal areas . 29Endocrine therapy . 29Pre-menopausal patients. 30Postmenopausal patients . 30Ovarian suppression for early invasive breast cancer . 30Tamoxifen for ductal carcinoma in situ . 31Male breast cancer . 31Chemotherapy . 31Neo-adjuvant chemotherapy . 31Biological therapy . 32Recurrent / metastatic disease . 33Hormonal therapy . 33Palliative cytotoxic chemotherapy. 33Clinical trials . 34Fertility issues . 34Assessment of bone loss . 34Complications of local treatment and menopausal symptoms . 34Lymphoedema . 34Arm mobility . 34Menopausal symptoms . 35Follow Up . 35Clinical follow up . 35Follow up mammography . 36Appendix 1 . 37Appendix 2 . 38Appendix 3 . 39Appendix 4 . 40Appendix 5 . reast-cancer-v1.doc7

Organisation of breast cancer surgical servicesThe multidisciplinary team (MDT)Breast cancer care should be provided by breast specialists in each discipline andmultidisciplinary teams form the basis of best practice. All new breast cancer patientsshould be reviewed by a multi-disciplinary team (MDT). This team is the forum forrecommending treatment regimens for individual patients. These guidelines form the basisfor discussion but do not preclude other treatments if deemed appropriate in individualcases. Participation in clinical trials is encouraged.Membership of each MDT will vary. The minimum requirement is the core membership.Core members of the MDT Designated breast ast care nurse(s)MDT Co-ordinatorExtended member of the MDT may include: Plastic and reconstructive surgeonData management personnelResearch nurse(s)Clinical psychologistPalliative care teamConsultants and other core team members must have contractual time for attendance at theMDT meeting. The team should meet at least weekly and there must be representativesfrom each of the core membership groups. Formal arrangements should be in place tocover for absence. Video-conferencing facilities may be required to permit discussionbetween the Cancer Centre and Local Units. A record of attendance should be kept and theoutcome of patient discussions should be recorded in the case notes. A designated memberof the clerical team should have the responsibility to co-ordinate the whole process.All new patients in whom a needle core biopsy has been taken should be discussed.Verified imaging and pathology results should be available at each MDT meeting. Allpatients diagnosed with breast cancer should be discussed prior to instigation of therapy –whether surgery, neo-adjuvant or primary medical therapy. Results of all required prognosticand predictive factors (including ER and HER2 status) should be available. All postoperativebreast cancer patients’ results should be discussed to decide appropriate adjuvant therapy.Patients should also be discussed who re-present with problems or a diagnosis of metastaticdisease.It is essential that mechanisms are in place for the timely reporting of MDT decision toprimary care. The MDT decision regarding the management of a newly diagnosed breastcancer should be communicated within 24 hours of the meeting by an appropriatemechanism such as secure fax. Mechanism should also be in place for the acceptance ofreferrals from other MDTs and the reporting of the decision back to the referring ent-of-breast-cancer-v1.doc8

in a consistent and timely fashion.

for-the-management-of-breast-cancer-v1.doc 8 . Organisation of breast cancer surgical services . The multidisciplinary team (MDT) Breast cancer care should be provided by breast specialists in each disciplineand multidisciplinary teams form the basis of best practice. All new breast cancer patients should be reviewed by a multi-disciplinary .