surgical aguidelines for the management of breast cancer

8/12/2019 Surgical AGuidelines for the Management of Breast Cancer

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Available online at www.sciencedirect.com

EJSO xx (2009) S1eS22 www.ejso.com

Guidelines

Surgical guidelines for the management of breast cancer

Association of reast Surger! at ASO2009

"#$%O&'$"O#

$he ublication of the first *idel! disseminated guidelines for surgeons on the management of breast cancer in the 'nited

+ingdom in 1992 follo*ed the introduction of the #ational ,ealth Ser-ice reast Screening .rogramme (#,SS.) in 19/and focussed on screendetected breast cancer

1Subse3uentl! guidelines for surgeons on the management of s!mtomatic

breast disease *ere ublished in 19942$he reast Grou at ASO (no* the Association of reast Surger! at ASO) *as

closel! in-ol-ed in the initiation and drafting of both documents 'dated -ersions of both screening and s!mtomaticguidelines ha-e subse3uentl! been ublished

"n 1994 the hief 5edical Officer ublished a .olic! 6rame*or7 for commissioning cancer ser-ices8 *hich suggested

that the care of malignant disease should be deli-ered through ancer entres and ancer 'nitsand that breast cancer

ser-ices should be managed through secialised deartments E3ui-alent standards of care should be deli-ered in ancer'nits as in ancer entres8 although some facilities such as radiothera! ma! not be a-ailable locall! in cancer units "ngeograhicall! isolated units multidiscilinar! consultation b! telemedicine ma! be aroriate to ensure exert care *herethe local oulation is small

"n 20008 the #,S ancer .lan *as ublished and romised imro-ed access and *aiting times for eole alread! diagnosed *ith or thought to ha-e cancer

:"n 20028 the #ational "nstitute of linical Excellence roduced udated guidelines on

imro-ing the outcomes for atients *ith breast cancer4

Subse3uentl! in 2008 the &eartment of ,ealth ublished theirne* cancer lan e $he ancer %eform Strateg!;$his aims to reduce morbidit! and mortalit! from cancer8 b! romoting

cancer re-ention8 imro-ing screening8 earl! diagnosis and treatment

$he management of breast cancer from the oint of diagnosis should essentiall! be the same8 *hether the cancer isdetected -ia breast screening or as the result of the in-estigation of breast s!mtoms $hese ne* unction *ith the udated


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Guidelines / ES! "" #$%%&' S(eS$$

SE$"O# 1C 5'B$"&"S".B"#A%D A%E

T)e breast multidisci*linar+ team #,-T'

"t is no* *idel! acceted that breast care should be ro-ided b! breast secialists in each disciline and thatmultidiscilinar! teams form the basis for best ractice $he constituent members of the reast $eam ma! be con-enientl!

di-ided into t*o searate but interdeendent grous

-ianostic Team

Cancer Treatment Team

-ianostic Team

As most atients do not ha-e breast malignanc!8 the role of the breast clinic is both to diagnose breast cancer and to treatand reassure atients *ith benign breast disorders $he 7e! comonent members of this grou areC

reast S*ecialist Clinician normall! a onsultant Surgeon *ith an interest in breast disease and their team *hichma!include Associate Secialists8 reast linicians8 Staff Grade Surgeons and Secialist $rainees

Secialist %adiologist and %adiograher.athologist (!toathologist and@or ,istoathologist) and Baborator! Suort Staff

reast are #urse

#urse .ractitioner

linic Staff

Administrati-e Staff

&edicated 5&$ oordinator

Cancer Treatment Team

$his *ill include members of the &iagnostic $eam as *ell as the follo*ingC

linical Oncologist

5edical Oncologist

.lastic and %econstructi-e Surgeon and@or Oncolastic reast Surgeon

5edical Geneticist

&ata 5anagement .ersonnel

%esearch #urse

B!mhoedema secialist

5edical .rosthetist

linical .s!chologist

.alliati-e are $eam

,ultidisci*linar+ team meetins

onsultants and other team members *ithin the breast unit must ha-e contractual time for attendance at the multidiscilinar! team meeting $he 5&$ meeting is b! definition a fixed clinical commitment 6or medical staff8 this should becounted as one session or .rogrammed Acti-it! (.A) $his reflects the time in-ol-ed in rearation8 the meeting itself and

ostmeeting administration "t is essential for trainees *ithin breast surger! and its related discilines to attend the 5&$meeting A record of attendance should be 7et8 and trainees should record attendance in their logboo7 $he conclusions of

atient discussion should be recorded in the case notes

A designated member of the clerical team (5&$ oordinator) should ha-e the resonsibilit! to coordinate this rocess$his ma! be shared *ith a secretarial or data management function $his is an imortant8 resonsible role and aroriatetime should be a-ailable to discharge this effecti-el!

ideoconferencing facilities should be a-ailable to ermit discussion bet*een units8 if re3uired $his is articularl! imortant for geograhicall! isolated units ,o*e-er8 this *ill also allo* discussion bet*een ancer entres and smallerancer 'nits


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.lease cite this article in ress asC Surgical guidelines for the management of breast cancer8 Association of reast Surger! at ASO 20098 Eur J SurgOncol (2009)8 doiC10101;@>e>so20090100/


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Although each unit ma! hold one 5&$ meeting each *ee78 atient decisions can be categoriFed as either

a &iagnostic

b $reatment lanning

c %eresentation

a &iagnostic

$his is *here ne* cases are discussed &iscussion should be considered for all cases *here a needle bios! has

been carried out and the diagnosis is not clearl! benign $he imaging and atholog! (core bios! @_ fine needleasiration) results should be a-ailable All atients diagnosed *ith breast cancer should be discussed rior to

instigation of thera! e *hether surger!8 neoad>u-ant or rimar! medical thera! %esults of all re3uired rognostic andredicti-e factors (including E% status and ideall! ,E%2 status and an! others used in that unit according to localguidelines) should be a-ailable for this discussion

b $reatment lanning

$his is also 7no*n as the u-ant treatment otions decided %esults of all re3uired rognostic and redicti-e factors (E%8 ,E%28 and an! others used in that unit according to local guidelines) must be a-ailable for thisdiscussion

c %eresentation

$his is *here a re-iousl! treated atient reresents *ith s!mtoms A common instance of this might be the reresentation of a atient *ith susicious s!mtoms and a diagnosis of metastatic disease

5ultidiscilinar! team meetings

?ualit! ob>ecti-es Outcome measures

A 5&$ meeting should ta7e lace to discuss atient management8 A 5&$ meeting should ta7e lace *ee7l! A record of the meeting8

before treatment otions are discussed *ith the atient including the attendance8 should be 7et

Ade3uate resources should be ro-ided to suort Each 5&$ should ha-e a 5&$ oordinator $he 5&$ meeting

a functioning 5&$ meeting should be a fixed clinical commitment

.lease cite this article in ress asC Surgical guidelines for the management of breast cancer8 Association of reast Surger! at ASO 20098 Eur J Surg Oncol(2009)8 doiC10101;@>e>so20090100/


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SE$"O# 2C &"AG#OS"S

Hhere-er ossible8 a nonoerati-e breast cancer diagnosis should be achie-ed b! trile assessment8 (clinical andradiological assessment follo*ed b! core bios! and@or fine needle asiration) Hhilst core bios! is referable due to theadditional information it can ro-ide8 there ma! be circumstances *here onl! a fine needle asiration is ossible

A nonoerati-e diagnosis should be ossible in the -ast ma>orit! of in-asi-e breast cancers8 *ith a minimum standard of

achie-ing this in at least 90I of cases and a target of more than 94I $he ma>orit! of nonin-asi-e breast cancers *ill bescreendetected and imalable8 ma7ing a nonoerati-e diagnosis otentiall! more difficult $he minimum standard for nonoerati-e diagnosis is at least /4I of cases for nonin-asi-e cancers *ith a target of more than 90I

-ianostic e"cisions

&iagnostic excision bios! is no* relati-el! unusual8 *ith the ad-ent of trile assessment and also the increasing use of-acuum assisted bios! for difficult cases ,o*e-er8 some breast lesions ma! still re3uire diagnostic excision8 if the core

bios! or 6#A is not benign ,ence lesions graded as @: or @: ma! still need to be remo-ed for definiti-e histolog!Such lesions are more li7el! to emanate from the #,SS. than the s!mtomatic clinic $o minimiFe atient anxiet!8 anoeration for diagnostic uroses should be *ithin t*o *ee7s of the decision to oerate 6or atients ha-ing surgicalremo-al of a athologicall! ro-en benign lesion the 1/ *ee7 target *aiting time *ill al!

All diagnostic bios! secimens should be *eighed 5ore than 90I of diagnostic biosies for imalable lesions8 *hichsubse3uentl! ro-e to be benign should *eigh less than 20 g in line *ith the current ?ualit! Assurance Guidelines forSurgeons in reast ancer Screening An! benign diagnostic resection secimen *eighing more than :0 g should bediscussed at the ostoerati-e 5&$ meeting and an! mitigating reasons recorded8 and if a screening case8 also discussed atthe next ?ualit! Assurance -isit to that unit

0ro1en section *at)olo+

6roFen sections *ith immediate athological reorting at surgical breast bios! should not be erformed excet in -er!unusual circumstances and the reasons documented

&iagnosis?ualit! ob>ecti-es Outcome measures

$o minimise the cosmetic imairment of diagnostic oen bios! $he fresh *eight of tissue remo-ed for all cases *here a diagnostic oen bios!

is erformed should be recorded

_90I of oen surgical biosies carried out for diagnosis8 *hich ro-e to

be benign8 should *eigh _20 gAll cases *here oen surgical diagnostic biosies *hich ro-e to be benign

and *eigh 2:0 g should be discussed at the ostoerati-e 5&$ meeting

and an! mitigating reasons recorded

$o minimise atient anxiet! bet*een a decision that a diagnostic .atients should be admitted for a diagnostic oeration *ithin 2 *ee7s

oeration is re3uired to confirm or exclude malignanc! and the 5inimum standard e _90I *ithin 2 *ee7sdate for an oeration $arget e 100I *ithin 2 *ee7s

$o minimise unnecessar! surger!8 ie oen surgical diagnostic "n-asi-e breast cancers should ha-e a nonoerati-e athological diagnosis

biosies that ro-e to be malignant 5inimum standard e_

90I

$arget e _94I#onin-asi-e breast cancers should ha-e a nonoerati-e athological diagnosis

5inimum standard e _/4I

$arget e _90I



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SE$"O# C $%EA$5E#$ .BA##"#G A#& .A$"E#$ O55'#"A$"O#

Each breast unit must ha-e *ritten guidelines for the treatment of breast cancer8 *hich ha-e been formulated and agreedb! the breast multidiscilinar! team $he treatment of atients should usuall! follo* these guidelines8 although it isacceted that there ma! be reasonable excetions $he reasons for not follo*ing guidelines should be discussed at the5&$ meeting and documented

6ollo*ing confirmation of a breast cancer diagnosis and aroriate 5&$ discussion to lan management8 the resultsshould be discussed *ith the atient .atients should be encouraged to bring a artner or friend *ith them *hen the resultsare being discussed $he erson conducting the consultation should be a member of the reast 5&$ and the breast carenurse should usuall! be resent "t should ta7e lace in an aroriate en-ironment *ith ade3uate ri-ac! $he follo* uarrangements should be clear and the atient must 7no* ho* to access the breast care nurse and other rele-antcomonents of their care lan

.atients must be gi-en ade3uate time8 information and suort in order to ma7e a full! informed decision concerningtheir treatment $his must include discussion of suitable treatment otions *ith the surgeon in liaison *ith the breast carenurse $he treatment otions offered should ha-e been agreed at a 5&$ meeting and the decisions agreed *ith the atientshould be recorded "n the e-ent of a atient refusing the recommended treatment otions this should be recorded

lose communication must be maintained bet*een surgeons and oncologists to lan rimar! treatment and to facilitatesubse3uent ad>u-ant thera! A care lan for each atient must be dra*n u "t must ta7e account of factors redicti-e of

both sur-i-al and of local or regional recurrence8 the age and general health of the atient8 the social circumstances andatient references $reatment lanning should allo* ade3uate time for discussion of oncolastic@reconstructi-e surgicalotions for those *omen *ho *ish to consider it

reast cancer at diagnosis can be broadl! classified into three clinical categoriesC

(A) Oerable rimar! breast cancer

$he ma>orit! of breast cancer cases8 resenting s!mtomaticall! or diagnosed through breast screening8 *ill fall into thiscategor! Surger! *ill usuall! be the first treatment and *ill be discussed in further detail in these guidelines

#eoad>u-ant endocrine treatment ma! be aroriate in some instances to do*nstage bul7! disease to facilitate breastconser-ing surger! in ost menoausal *omen *ith E% ositi-e breast cancers $here is currentl! no consensusregarding the use of neoad>u-ant chemothera! in this circumstance ,o*e-er the a-ailable data from randomised trialssho*s that breast conser-ing surger! after neoad>u-ant thera! is associated *ith a significantl! increased ris7 of local

recurrence Hhere neoad>u-ant thera! is being considered the increased ris7 of local recurrence should be discussed*ith *omen and ta7en into consideration gi-en the recent reorts from the Oxford o-er-ie* *hich sho*s that thea-oidance of local recurrence in the conser-ed breast re-ents about one breast cancer death for e-er! four such

recurrences a-oided

() Bocall! ad-anced rimar! breast cancer

$he management of locall! ad-anced rimar! breast cancer should be multidiscilinar! and *ill initiall! re3uire a corebios! and staging in-estigations "n some atients medical treatment (hormonal@chemothera!) and@or radiationthera! ma! be the most aroriate initial treatment $he management of locall! ad-anced rimar! breast cancer *illnot be discussed further in these guidelines

() 5etastatic breast cancer

6ollo*ing the s!mtomatic resentation of distant metastases8 a-erage life exectanc! is aroximatel! 2 !ears8 *ith-irtuall! all atients e-entuall! d!ing from breast cancer $he aim of treatment is to alliate s!mtoms and to maintainthe highest ossible 3ualit! of life $he management of atients *ith metastatic breast cancer should bemultidiscilinar! Although the ma>orit! of atient care is li7el! to be deli-ered b! oncologists and the alliati-e careteam some surgeons *ith established exerience in this field ma! continue to be in-ol-ed in the multidiscilinar! team"n addition all breast surgeons need to be in-ol-ed *ith the local control of the disease $he management of metastatic

breast cancer *ill not be discussed further in these guidelines

Recurrent breast cancer

A multidiscilinar! aroach is needed in the management of atients *ith recurrent breast cancer All atients resenting

*ith recurrent breast cancer should be restaged rior to definiti-e management A significant roortion of atients resenting



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*ith ecti-es Outcome measures

reast cancer treatment should be ro-ided in a consistent manner Each breast unit must ha-e *ritten guidelines for the management

according to agreed local guidelines of breast cancer

$he management of atients *ith breast cancer should be $he management of all atients *ith ne*l! diagnosed breast cancer

discussed b! a multidiscilinar! team should be discussed at a 5&$ meeting and the conclusions

documented in each atient=s notes



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SE$"O# :C O%GA#"SA$"O# O6 %EAS$ A#E% S'%G"AB SE%"ES

Personnel

Surgical treatment of atients *ith breast cancer must be carried out b! surgeons *ith a secial interest and training in

breast disease/e10

(Be-el e-idence) Each surgeon in-ol-ed in the #,S S. should maintain a surgical caseload of at least

10 screendetected cancers er !ear8 a-eraged o-er a three !ear eriod "t is exected that surgeons *ith lo* caseloads shouldbe able to demonstrate an annual surgical *or7load of at least 0 treated breast cancers reast surgeons should *or7 in breastteams8 *hich ha-e the necessar! exertise and facilities for a multidiscilinar! aroach

3aitin times 4or surical treatment

Hhen a decision has been reached to offer surgical treatment8 atients should be offered a date for oeration rather than belaced on a *aiting list %econstruction rocedures *ill re3uire logistical lanning but should not lead to unnecessar! dela!All diagnostic and theraeutic oerations are urgent

$he #,S ancer .lan:states that atients should ha-e a maximum *ait of 1 da!s from


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SE$"O# 4C S'%GE%D 6O% "#AS"E %EAS$ A#E%

T+*e o4 breast surical *rocedure

Bong term follo* u of randomised clinical trials ha-e reorted similar sur-i-al rates for *omen treated b! mastectom!or breast conser-ation surger!

1:

e1;,o*e-er all of these studies had selection criteria and indeed the -ast ma>orit! of

atients in these studies resented *ith tumours 624 cmsAccurate reoerati-e assessment of the siFe and extent of the tumour is essential for deciding *hether breast con

ser-ation surger! is an alternati-e otion to mastectom! %outine methods for assessing the extent of disease in the breast areclinical examination8 mammograh! and ultrasound "n a significant number of cases the true extent of disease isunderestimated8 articularl! *ith in-asi-e lobular cancer Selecti-e use of magnetic resonance imaging (5%") ma! be usefulin lanning surgical treatment and in articular ifC there is a discreanc! bet*een the clinical and radiological estimatedextent of disease if there is a dense breast attern on mammograh! or the diagnostic core bios! suggests an in-asi-elobular cancer $he decision to offer 5%" should be discussed at the 5&$ meeting and be according to local guidelines

Hhilst man! *omen ma! be suitable for breast conser-ation surger!8 -arious factors (eg biological8 atient choice) ma!lead to some *omen being ad-ised or choosing to ha-e a mastectom! for their disease

Hhere-er ossible8 atients should be offered an informed choice bet*een breast conser-ation surger! and mastectom!.atients choosing or ad-ised to ha-e mastectom! for in-asi-e breast cancer should ha-e the oortunit! to discuss *hether

breast reconstruction is aroriate and feasible $he reasons for not offering choice and@or breast reconstruction to a atientshould be documented in the atient=s case notes

,arins o4 e"cision

.atients undergoing breast conser-ation surger! should routinel! ha-e malignant tumours excised *ith microscoicall!clear radial margins lose margins at the chest *all or near the s7in ma! be less imortant Hhere breast tissue is to bemo-ed at the time of surger! (eg oncolastic techni3ues) articular consideration must be gi-en to ensuring that furtherexcision of in-ol-ed margins can be easil! carried out *ithout a atient er se being committed to a mastectom!

"ntraoerati-e secimen radiograh! is mandator! for imalable lesions re3uiring radiological localiFation8 andrecommended for all *ide local excision rocedures &edicated e3uiment (eg8 digital secimen radiograh! cabinet) should

be a-ailable so that a radiograh can be ta7en of the secimen and reorted to or b! the surgeon *ithin 20 minutes"nterretation of secimen radiograhs must be clearl! recorded "f this is done b! the oerating surgeon8 the result must beconfirmed b! the radiologist at the subse3uent multidiscilinar! team meeting "f the radiologist reorts the film at once8 nomore than 20 minutes should elase before the reorted film is recei-ed b! the oerating surgeon "f a secimen radiograhis erformed8 this should be a-ailable to the reorting athologist $he surgeon should orientate and mar7 the secimen riorto deli-er! to the athologist $he breast unit must ha-e a clear rotocol for secimen orientation and the handling of

athological secimens ,istologicall! in-ol-ed margins lead to an excessi-el! high ris7 of local recurrence8 e-en if ad>u-antradiothera! is gi-en Aroximatel! one in four atients *ith later local recurrence *ill succumb to their disease8 *ho

other*ise *ould not ha-e died of breast cancer if the! had not de-eloed a local recurrence

$here are no data to suort a secific margin of excision $here are no randomised trials of margins of excision Hhile

further occult foci of disease can be found more than 2 cm from the suosed margin in u to :I of atients1

the *ider the

margin the less occult foci are found Hhilst #"E ha-e re-iousl! recommended a minimum margin of 2 mm84there are nodata to substantiate this 'nits should ha-e local guidelines regarding accetable margin *idth and indi-idual cases should

be discussed at the treatment 5&$ meeting "f8 after 5&$ meeting discussion8 the margin of excision is deemed to beinade3uate then further surger! to obtain clear margins should be recommended

,ar7in o4 surical cavities in breast conservation surer+

#e* ad-ances in radiation thera! ha-e led to more accurate and consistent lanning and deli-er! of thera! "ntensit! mod

ulated radiothera! ("5%$) is no* increasingl! used to deli-er satisfactor! treatment doses to the clinical tumour -olume8 *hilst

also ro-iding the abilit! to sare normal tissues onsistent and accurate localisation of the tumour resection bed after breast

conser-ation is imortant if the full benefits of "5%$and further radiothera! ad-ances are to be obtained .re-ious studies ha-e



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sho*n that estimating the tumour bed from the osition of the surgical scar is inaccurate $he mar7ing of the tumour bed iseseciall! imortant *hen oncolastic techni3ues are used to imro-e the cosmetic outcome $he insertion of mar7ers8 such assurgical clis or gold seeds8 in the tumour bed b! the oerating surgeon ro-ides a *a! of -isualising the tumour bed Surgicalclis are eas! and chea and allo* radiothera! lanning either b! $ or 7ilo-oltage exit ortals Surgeons referring to radiothera! centres using mega-oltage exit ortals ma! need to consider the use of gold seeds8 as clis cannot al*a!s be easil!-isualised on mega-oltage e3uiment

Local recurrence rates

$he main aim of surger! is to achie-e good local control of both the rimar! tumour and the regional nodes in the axilla "natients *ith oerable breast cancer8 comlete excision of the rimar! tumour *ith clear margins is essential $he ma>orrandomised trials of breast conser-ation surger! and radiothera! -ersus mastectom! for in-asi-e cancer reort local re

currence rates for breast conser-ation surger! ranging bet*een I at ; !ears to 1I at 10 !ears and for mastectom! rangingbet*een 2I at 10 !ears and 9I at / !ears

1:e1;81/

although as noted abo-e the ma>orit! of tumours in these trials *ere624 cms

,o*e-er8 the S$A%$ trial has no* reorted and sho*s excellent lo* rates of local recurrence (4I at 4 !ears) follo*ing

breast conser-ation surger! in the '+19

,ence the recommended minimum standards and targets for local recurrence afterbreast conser-ation surger! for in-asi-e cancer ha-e been re-ised to a maximum of 4I at 4 !ears and a target of 6I at 4

!ears

Surger! for in-asi-e breast cancer


.atients should be full! informed of the surgical treatment otions Hhen aroriate atients should be gi-en an informed choice

a-ailable to them bet*een breast conser-ation surger! and mastectom! "f a choice ofbreast conser-ation surger! is not offered the reasons should bedocumented in the atient=s case notes

.atients should ha-e access to breast reconstruction surger! All atients ha-ing treatment b! mastectom! (b! choice or on ad-ice)should ha-e the oortunit! to discuss their breast reconstruction otionsand ha-e immediate breast reconstruction if aroriate "f breastreconstruction is not offered the reasons should be documented in the

atient=s case notes

$o ensure ade3uate assessment of surgical excision of an in-asi-e "ntraoerati-e secimen radiograh! should be carried out for all cases

cancer treated b! breast conser-ation surger! re3uiring radiological localisation and is recommended for all *ide localexcision secimens

All secimens must be mar7ed b! the surgeon according to localrotocols to allo* orientation b! the reorting athologist

$o ensure ade3uate surgical excision of an in-asi-e cancer treated All atients should ha-e their tumours remo-ed *ith no e-idence of

b! breast conser-ation surger! disease at the microscoic radial margins and fulfilling the re3uirementsof local guidelines

"f8 after 5&$ meeting discussion8 the margin of excision is deemedto be inade3uate then further surger! to obtain clear margins shouldbe recommended

$o minimise the number of theraeutic oerations in *omen 5inimum standard e 294I of atients should ha-e three or fe*er oerations

undergoing conser-ation surger! for an in-asi-e cancer $arget e 100I of atients should ha-e _ oerations

$o minimise local recurrence after breast conser-ation surger! 5inimum standard e 64I of atients treated b! breast conser-ationfor in-asi-e malignanc! surger! should de-elo local recurrence *ithin 4 !ears

$arget e 6I of atients treated b! breast conser-ation surger! shouldde-elo local recurrence *ithin 4 !ears

$o minimise local recurrence after mastectom! for in-asi-e malignanc! 5inimum standard e 64I of atients treated b! mastectom! shouldde-elo local recurrence *ithin 4 !ears

$arget e 6I of atients treated b! mastectom! should de-elo localrecurrence *ithin 4 !ears


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SE$"O# ;C AK"BBA%D #O&E 5A#AGE5E#$ "# "#AS"E %EAS$ A#E%

$he resence of axillar! node metastases is the most o*erful rognostic determinant in rimar! oerable breast cancer andits assessment re3uires histological examination of excised axillar! l!mh nodes Aroriate management of the axilla is alsoimortant in the re-ention of uncontrolled axillar! relase Axillar! relase is defined as relase in the axilla itself and doesnot include suracla-icular recurrence

Some atients *ith in-asi-e breast cancer ma! be diagnosed *ith axillar! disease rior to definiti-e surger! $he use of reoerati-e axillar! assessment *ith ultrasound and aroriate fine needle asiration (or core bios! if feasible) can !ield adiagnosis of in-ol-ed nodes in some cases "f a ositi-e nonoerati-e diagnosis of axillar! nodal metastasis is made in a

atient *ith earl! breast cancer8 that atient should normall! roceed to an axillar! clearance "f an axillar! clearance is carriedout all axillar! l!mh nodes should be remo-ed unless there are secific reasons or unit olicies not to do this "n the lattercases the anatomical le-el of dissection should be secified in the oeration note $he number of nodes retrie-ed from axillar!node clearance histolog! secimens *ill be both surgeon and athologist deendent ,o*e-er8 for a full axillar! clearance atleast 10 nodes should be retrie-ed in 290I of cases

"deall!8 all atients *ith earl! in-asi-e breast cancer should ha-e axillar! staging and if ositi-e for metastasis8 treatment foraxillar! disease "f an axillar! staging rocedure is not to be carried out the reasons for this should be discussed at the 5&$meeting and documented in the atient=s case notes

omlete axillar! clearance (le-el ) is effecti-e in controlling regional disease %ecurrence rates of Ie4I at 4 !ears ha-e

been reorted820

e2

but some of these studies *ith le-el 2 clearance included both l!mh node negati-e and ositi-e cases "t is

suggested that axillar! node recurrence should be less than 4I at fi-e !ears *ith a target of less than I Besser degrees ofsurger! *ithout axillar! radiothera! lead to corresondingl! higher rates of axillar! recurrence $he Edinburgh stud! onatients recei-ing selecti-e axillar! radiothera! for ositi-e nodes after axillar! samling demonstrated similar control to that

of full (le-el ) axillar! clearance2082:

(Be-el 2 e-idence)

"n the last fe* !ears8 sentinel node bios! (S#) has become a standard aroach for axillar! staging $his techni3uero-ides accurate assessment of the axilla8 *ith fe* false negati-es and a significant reduction in surgical morbidit!8 ese

ciall! l!mhoedema24

reast surgeons are encouraged to adot the S# techni3ue and ta7e art in the #EH S$A%$ ore3ui-alent training rogrammes $he combined techni3ue (blue d!e and radioisotoe) is the recommended method Surgeonsshould be able to achie-e minimum standards *ith a 290I sentinel node identification rates and 610I false negati-e rateso-er a minimum 0 case audit series

Surgical staging of the axillar! l!mh nodes should be erformed according to local rotocols "f there is a nonoerati-ediagnosis of in-asi-e malignanc!8 then an axillar! staging rocedure should be carried out at the same time as surger! to resectthe rimar! tumour other than in excetional circumstances eg8 rior to immediate B& fla reconstruction Axillar! staging

ma! be achie-ed b! sentinel node bios! (recommended in the ma>orit!)8 samling8 or clearance "f axillar! node samling iscarried out then at least : nodes should be obtained lue d!e ma! be used to augment axillar! node samling and if used thisshould be documented in the oeration note %outine use of axillar! node clearance as an axillar! staging rocedure *ill beo-er treatment for the ma>orit! of atients

Hhere the sentinel node is ositi-e (macrometastasis or micrometastasis)8 further axillar! treatment (axillar! dissection orradiothera!) as *ell as ad>u-ant s!stemic thera! is recommended ,o*e-er8 the management of atients *ith ositi-esentinel nodes is currentl! under in-estigation $he EO%$A5A%OS trial comares axillar! clearance -ersus radiothera!$he AOSOG L0011 trial comares axillar! clearance -ersus obser-ation onl! $hese studies *ill not reort for some time$he decision to carr! out a comletion (full) axillar! clearance or to gi-e axillar! radiothera! if the sentinel node is ositi-eshould be discussed at the 5&$ meeting and *ith the atient8 be according to local guidelines8 and be documented in the

atient=s case notes $he significance of isolated tumour cells in axillar! l!mh nodes is currentl! uncertain and these should beregarded as l!mh node negati-e and routine axillar! treatment is not recommended



12/26

ARTICLE IN PRESS

Guidelines / ES! "" #$%%&' S(eS$$ S11

Axillar! node management in in-asi-e breast cancer


$o increase the nonoerati-e diagnosis of axillar! node metastases $arget e all atients diagnosed *ith in-asi-e breast cancer undergoing surgical

treatment should ha-e a reoerati-e axillar! ultrasound scan8 and if

aroriate 6#A or core bios! should be carried out

$o ensure ade3uate surgical treatment of in-ol-ed axillar! "f a ositi-e nonoerati-e diagnosis of axillar! nodal metastasis is made inl!mh nodes a atient undergoing surger! for breast cancer8 the atient should normall!

roceed to an axillar! clearance

.atients *ith ositi-e (macrometastases or micrometastases) axillar! staging

rocedures should roceed to subse3uent treatment for axillar! disease

$his ma! ta7e the form of comletion (ie8 full) axillar! clearance8 axillar!

radiothera! or entr! into an aroriate clinical trial $his should be discussed

at the 5&$ meeting according to local guidelines and the reasons should be

documented in the atient=s case notes

Hhen axillar! node clearance is carried out8 the le-el of anatomical dissection

should be secified8 and at least 10 nodes should be retrie-ed

5inimum standard e 290I$arget e 100I

$o ensure ade3uate staging of the axilla in atients *ith .atients treated surgicall! for earl! in-asi-e breast cancer should ha-e an

in-asi-e breast cancer axillar! staging rocedure carried out if metastatic nodal metastasis is not

confirmed nonoerati-el!


Hhen axillar! node samling is carried out at least : nodes should be retrie-ed


$o minimise morbidit! from axillar! surger! to obtain Sentinel node bios! using the combined blue d!e@radioisotoe techni3ue

staging information is a recommended axillar! staging rocedure for the ma>orit! of atients *ith

earl! in-asi-e breast cancer

Axillar! recurrence should be minimised b! effecti-e staging andtreatment *here aroriate

5inimum standard e 64I axillar! recurrence at 4 !ears $arget e 6I

axillar! recurrence at 4 !ears



13/26

ARTICLE IN PRESS

S12 Guidelines / ES! "" #$%%&' S(eS$$

SE$"O# C S'%G"AB 5A#AGE5E#$ O6 &'$AB A%"#O5A "# S"$'

&uctal carcinoma in situ (&"S) is a malignant recursor of in-asi-e breast cancer $he aim of surger! is to achie-e comlete excision of the in situ tumour and to minimise local recurrence $he grade of the tumour

2;and clear resection margins (21

mm margin)2

are imortant factors in the management of &"S

$umour multifocalit! is not uncommon and can lead to high local failure rates2/

Aroximatel! 40I of local relases after

treatment for &"S are in-asi-e and not in situ $he indications for mastectom! are uncertain but extensi-e micro calcificationon the reoerati-e mammogram is a ris7 factor for local recurrence after conser-ation surger! ,igh recurrence rates occur*ith larger tumours (2:0 mm diameter) and mastectom! should be considered for such cases Hhile mammograhic findingsdo not al*a!s corresond to athological siFe the mammograhic siFe is more commonl! an underestimate of the finalhistological siFe "f mastectom! is being considered for the treatment of &"S on the basis of multifocalit!8 then at least t*oareas of the breast should ideall! be biosied to confirm this

$here ha-e been randomised trials of ad>u-ant radiothera! after breast conser-ation for &"S "n the EO%$ stud!82

clearmargins (21 mm) *ere associated *ith a local recurrence rate of 14I at 4 !ears comared to ;I in atients *ith close orin-ol-ed margins (61 mm or fran7l! in-ol-ed)8 regardless of the use of radiothera! Bi7e*ise8 lo* grade &"S is associated*ith a lo* ris7 of recurrence

.atients undergoing breast conser-ing surger! should routinel! ha-e the &"S excised *ith microscoicall! clear radialmargins lose margins at the chest *all or near the s7in ma! be less imortant Hhere breast tissue is to be mo-ed at the timeof surger! (eg oncolastic techni3ues) articular consideration must be gi-en to ensuring that further excision of in-ol-edmargins can be easil! carried out *ithout a atient er se being committed to a mastectom!

"ntraoerati-e secimen radiograh! should be carried out for all cases of &"S treated b! breast conser-ation surger!8 the-ast ma>orit! of *hich *ill be imalable lesions re3uiring radiological localiFation &edicated e3uiment (eg8 digitalsecimen radiograh! cabinet) should be a-ailable so that a radiograh can be ta7en of the secimen and reorted to or b! thesurgeon *ithin 20 minutes "nterretation of secimen radiograhs must be clearl! recorded "f this is done b! the oeratingsurgeon8 the result must be confirmed b! the radiologist at the subse3uent multidiscilinar! team meeting "f the radiologistreorts the film at once8 no more than 20 minutes should elase before the reorted film is recei-ed b! the oerating surgeon "fa secimen radiograh is erformed8 this should be a-ailable to the reorting athologist $he surgeon should orientate andmar7 the secimen rior to deli-er! to the athologist $he breast unit must ha-e a clear rotocol for secimen orientation andthe handling of athological secimens

$here are no data to suort a secific margin of excision 'nits should ha-e local guidelines regarding accetable margin*idth for &"S and indi-idual cases should be discussed at the treatment 5&$ meeting "f8 after 5&$ meeting discussion8 themargin of excision is deemed to be inade3uate then further surger! to obtain clear margins should be recommended

B!mh node staging is not normall! re3uired for atients *ith a nonoerati-e diagnosis of &"S alone ,o*e-er8 someatients ma! be at high ris7 of an occult in-asi-e carcinoma being found at subse3uent athological examination $hese *ouldinclude atients undergoing surger! forC an extensi-e area of microcalcification a alable mass high grade disease or *heremicroin-asion or fran7 in-asion is susected on the nonoerati-e biosies "n such cases S# or four node samling ma! beconsidered Axillar! clearance is contraindicated in the treatment of atients *ith a nonoerati-e diagnosis of &"S alone$he decision to carr! out an axillar! staging rocedure should be discussed at the 5&$ meeting and *ith the atient8 beaccording to local guidelines8 and be documented in the atient=s case notes

$he management of screen detected nonin-asi-e breast cancer (and at!ical h!erlasias) is the sub>ect of a national audit8the Sloane .ro>ect All breast screening units should articiate in this



14/26

ARTICLE IN PRESS


Surger! for ductal carcinoma in situ


.atients *ith &"S should be full! informed of the Hhen aroriate8 atients should be gi-en an informed choice bet*een breast conser-ationsurgical treatment otions a-ailable to them surger! and mastectom! $his includes the difference in local recurrence rates bet*een the t*o

aroaches "f a choice of breast conser-ation surger! is not offered the reasons should bedocumented in the atient=s case notes

.atients *ith &"S should ha-e access to breastconser-ation surger!

All atients ha-ing treatment b! mastectom! (b! choice or on ad-ice) should ha-e the oortunit! todiscuss their breast reconstruction otions and ha-e immediate breast reconstruction if aroriate"f breast reconstruction is not offered the reasons should be documented in the atient=s case notes

$o ensure ade3uate assessment of surgical excision of&"S treated b! breast conser-ation surger!

"ntraoerati-e secimen radiograh! should be carried out for all cases of &"S treated b! breastconser-ation surger!

All secimens must be mar7ed b! the surgeon according to local rotocols to allo* orientation b!the reorting athologist

$o ensure ade3uate surgical excision of &"S treated b!breast conser-ation surger!

All atients should ha-e their tumours remo-ed *ith no e-idence of disease at the microscoic radialmargins and fulfilling the re3uirements of local guidelines

"f8 after 5&$ meeting discussion8 the margin of excision is deemed to be inade3uate then furthersurger! to obtain clear margins should be recommended

$o minimise the number of theraeutic oerations in 5inimum standard e 294I of atients should ha-e three or fe*er oerations*omen undergoing conser-ation surger! for &"S $arget e 100I of atients should ha-e _ oerations

$o minimise local recurrence after breast conser-ation .atients *ith extensi-e (2:0 mm diameter) or multicentric disease should usuall! undergosurger! for &"S treatment b! mastectom!

$o minimise morbidit! from axillar! surger! Axillar! staging surger! is not routinel! recommended for atients ha-ing treatment for &"Salone "t ma! be considered in atients considered to be at high ris7 of occult in-asi-e disease$he decision to carr! out an axillar! staging rocedure should be discussed at the reoerati-e5&$ meeting and recorded in the atient=s case notesAxillar! node clearance is contraindicated in atients *ith &"S alone

$o minimise local recurrence after breast conser-ation $arget e 610I of atients treated b! breast conser-ation surger! should de-elo localsurger! for &"S recurrence *ithin 4 !ears

$o increase understanding of the diagnosis and All breast screening units should articiate in the national audit of the management oftreatment of &"S nonin-asi-e breast cancer8 the Sloane .ro>ect



15/26

ARTICLE IN PRESS

S1: Guidelines / ES! "" #$%%&' S(eS$$

SE$"O# /C S'%GE%D 6O% BO'BA% "# S"$' #EO.BAS"A

Bobular in situ neolasia8 B"S#8 (formerl! 7no*n as lobular carcinoma in situ or B"S) is often an incidental finding andis usuall! occult B"S# ma! not be a local malignant recursor lesion8 but it does confer an increased future ris78 aroxi

matel! se-enfold8 of in-asi-e breast cancer in both breasts29

e2

(Be-el e-idence) $he ris7 of de-eloing breast cancer isaroximatel! 1I er !ear

"t is suggested that breast lesions containing B"S# should be excised for definiti-e diagnosis8 as some atients ma! ha-e acoexisting in-asi-e malignanc! $he limited data a-ailable on B"S# suggests that clear resection margins are not re3uiredfollo*ing surger! for B"S# alone A olic! of close sur-eillance after excision bios! is aroriate (Be-el e-idence)

$he management of screen detected B"S# is included in a national audit8 the Sloane .ro>ect All breast screening unitsshould articiate in this

%ecommendations

- .atients *ith a reoerati-e diagnosis of B"S# should be considered for diagnostic excision bios!

- .ostoerati-e sur-eillance is aroriate in these atients as the! ha-e an ele-ated ris7 of subse3uent breast cancer

- Each breast unit should ha-e agreed sur-eillance guidelines for atients treated for conditions that lead to an increased ris7 of later breast malignanc!(such as B"S# A&, etc)

- All breast screening units should articiate in the Sloane .ro>ect

.lease cite this article in ress asC Surgical guidelines for the management of breast cancer8 Association of reast Surger! at ASO 20098 Eur J Surg


16/26

Oncol (2009)8 doiC10101;@>e>so20090100/


17/26

ARTICLE IN PRESS


SE$"O# 9C %EAS$ %EO#S$%'$"O#

All atients8 in *hom mastectom! is a treatment otion8 should ha-e the oortunit! to recei-e ad-ice on breast reconstructi-e surger! #ot all atients *ill be h!sicall! fit for or *ish to consider reconstruction "f this is not a-ailable *ithin the

breast unit8 the breast team should ha-e a recognised line of referral to a breast or lastic surgeon *ith articular exertise inbreast reconstruction $imel! access for atients considering reconstruction is essential in order that the! are not discouraged

b! the rocess6or atients8 *ho exress an interest in breast reconstruction8 discussions should ta7e lace on the ideal timing of the recon

struction $his should include the ris7s and benefits of immediate -ersus dela!ed techni3ues "deall! breast units should ha-eclinicians *ith oncolastic exertise M@or breast surgeons *ho *or7 *ith lastic and reconstructi-e surgeons *ith anestablished interest in breast reconstruction8 *ho can ro-ide this ser-ice Hhere units offer breast reconstruction8 ade3uatefacilities8 including theatre time and outatient clinic time to counsel atients rior to surger! should be a-ailable 6acilitiesshould be a-ailable for re-isional surger!

6urther guidance has been ublished b! the Association of reast Surger! at ASO8 the ritish Association of .lastic8%econstructi-e and Aesthetic Surgeons and the $raining "nterface Grou in reast Surger!C Oncolastic breast surger! e a

guide to good ractice

6or atients undergoing mastectom! *ithout immediate reconstruction8 a ser-ice should be ro-ided to sul! and fit breastrostheses

reast reconstruction


.atients should ha-e access to breast reconstruction surger! All atients ha-ing treatment b! mastectom! (b! choice or on ad-ice) should ha-e theoortunit! to discuss their breast reconstruction otions and ha-e immediate breastreconstruction if aroriate "f breast reconstruction is not offered the reasons shouldbe documented in the atient=s case notes

reast 'nits should ha-e surgeons *ith oncolastic exerience M@or ha-e the raida-ailabilit! of a lastic surgeon

Ade3uate time for consultation and surger! must be a-ailable

.atients not undergoing immediate breast reconstruction reast rostheses should be freel! a-ailable to atients treated b! mastectom! togethershould be ro-ided *ith breast rostheses *ith eas! access to a fitting ser-ice



18/26

ARTICLE IN PRESS

S1; Guidelines / ES! "" #$%%&' S(eS$$

SE$"O# 10C .E%" M .OS$O.E%A$"E A%E

Peri5o*erative and 4ollow u* care

.atients should be suorted b! a breast care nurse or a clinical nurse secialist8 *ho is a member of the breast team and*ho should ha-e established lin7s *ith outatient8 *ard and communit! nurses to assist in continuit! of care 6ollo*ing

mastectom! (*ithout immediate breast reconstruction)8 the fitting and sul! of breast rostheses should be exlained toatients .atients should be informed about the range of ser-ices a-ailable to them and be ro-ided *ith literature to includedetails of follo* u treatment and local self hel suort grous

Communication wit) General Practitioners

$he breast team should ensure that rimar! care ractitioners (G.s) recei-e communications that gi-e them a clear andraid understanding of the diagnosis8 care lan8 and toxicit! rofile of an! roosed treatment "t is the resonsibilit! of clinical trialists to ensure that G.s are full! briefed about an! trial for *hich the atient is entered and the otential side effects

Treatment multidisci*linar+ team meetin

All atients *ith breast cancer should ha-e their cases discussed after definiti-e surger! $his is commonl! 7no*n as theu-ant treatments should be discussed and thedecisions recorded in the atient=s case notes An oncologist should be resent at this meeting

.eri and ostoerati-e care


$o ensure breast cancer atients recei-e ade3uate suort All )atients treated for breast cancer should be su))orted b! a breast care nurse or clinicaland treatment throughout their care nurse secialist throughout their care

Ade3uate information about follo* u and suort grous should be made a-ailable

$o ensure ade3uac! of surgical treatment and lan ad>u-anttreatments

All atients should be discussed at the e>so20090100/


19/26

ARTICLE IN PRESS


SE$"O# 11C A&J'A#$ $%EA$5E#$S

Hritten local breast cancer treatment guidelines should identif! *hich atients should be considered for ad>u-anttreatments All atients should be discussed at the u-ant s!stemic treatments ha-e been sho*n to reduce the ris7 of recurrence and to imro-e o-erall sur-i-al

Ad>u-ant treatments should not be decided uon based on relati-e ris7 reduction calculations $he use of ad>u-anttreatments should be decided after a calculation has been made of an indi-idual atient=s absolute ris7 of recurrence andthe absolute benefit of a roosed treatment either alone or in combination *ith another treatment

Bocal ad>u-ant treatment guidelines should include the follo*ing areas

#a' Radiot)era*+

reast radiot)era*+ 4or invasive breast cancer

.atients *ho ha-e undergone breast conser-ation for rimar! in-asi-e breast cancer should be treated *ith ad>u-antradiothera! to the breast

81:81481/(Be-el 1 e-idence)8 unless radiothera! is contraindicated or the atient is entered into

a clinical trial

C)est wall radiot)era*+ *ost mastectom+ 4or invasive breast cancer

.atients treated b! mastectom! *ith higher ris7 disease ma! also be considered for ad>u-ant chest *all radiothera! $here ise-idence of reduced local recurrence *ith ostoerati-e radiothera! and of imro-ed sur-i-al in atients *ith higher ris7 disease

:845ore recent unublished data8 from the Oxford O-er-ie* 20048 sho*ed a reduction in local recurrence and imro-ed

sur-i-al for atients *ith an! node ositi-e disease after mastectom!1;

A"illar+ radiot)era*+ 4or invasive breast cancer

.atients *ith histologicall! negati-e nodes after ade3uate surgical axillar! assessment should not recei-e axillar! radiothera! #ode ositi-e atients *ho ha-e undergone axillar! clearance need not be treated *ith radiothera! unless multidiscilinar! re-ie* suggests that there is a articularl! high ris7 of regional relase8 eg8 if extensi-e extranodal sread oftumour seen $he otential benefit of dual treatment should be balanced against an increased ris7 of l!mhoedema 5ost

atients *ith histologicall! in-ol-ed axillar! nodes follo*ing sentinel node bios! or node samling should ha-eradiothera! if a subse3uent axillar! node clearance has not been carried out $he re3uirement for radiothera! to thesuracla-icular nodal regions should be determined at the 5&$ meeting and follo* the agreed local guidelines

reast irradiation 4or *atients wit) ductal carcinoma in situ #-CIS'.atients *ho ha-e been treated b! mastectom! for &"S do not re3uire ad>u-ant radiothera!

Se-eral ublished randomised trials and a later metaanal!sis of local excision alone -ersus excision and radiothera! ha-e

demonstrated a significant reduction in the ris7 of isilateral in-asi-e and nonin-asi-e recurrence in the radiothera! grou after

long term follo* u28;

e9

(Be-el 1 e-idence) $hese studies suggest that radiothera! reduced the haFard ratio for local

recurrence b! ;0I Hhile8 no difference in o-erall sur-i-al has been noted in the atients treated *ith radiothera! none ofthese trials *ere o*ered to sho* a sur-i-al difference $he fact that 40I of local recurrences after breast conser-ationsurger! for &"S are actuall! in-asi-e disease and the recent established lin7 bet*een local recurrence of in-asi-e diseaseand subse3uent ris7 of death from breast cancer should be ta7en into consideration *hen deciding *hether or not to omitad>u-ant radiothera! follo*ing breast conser-ation surger! for &"S

5&$ discussion of the need for radiothera! should ta7e lace for all cases of &"S treated b! breast conser-ation surger!8but the -alue of radiothera! *ill be related to the ris7 of local relase and should follo* the agreed local guidelines

A"illar+ radiot)era*+ 4or *atients wit) ductal carcinoma in situ #-CIS'Axillar! radiothera! should not be gi-en to atients8 *ho ha-e been diagnosed *ith &"S alone

#b' Endocrine t)era*+

All atients *ith E% ositi-e in-asi-e breast carcinoma can otentiall! benefit from hormonal thera!:0

(Be-el 1 e-idence) ,ormonal thera! reduces the haFard ratio of death from breast cancer b! aroximatel! 0I $his effect is inde

endent of rogesterone recetor status8 atient age and concomitant chemothera! use A decision *hether or not to useendocrine thera! should be based on an assessment of the absolute benefit and the ris7s or side effects of treatment $reatment regimes should be described in local rotocols



20/26

ARTICLE IN PRESS

S1/ Guidelines / ES! "" #$%%&' S(eS$$

urrent otions for endocrine treatment include tamoxifen8 aromatase inhibitors (anastraFole8 exemestane8 letroFole)8 rogestogens8 luteinising hormone releasing hormone (B,%,) analogues and oohorectom! b! radiothera!8 laarosco! oroen surger!

$he Earl! reast ancer $rialists= ollaborati-e Grou (E$G) Oxford O-er-ie* sho*s that *omen *ith E%negati-e in-asi-e tumours deri-e no benefit from hormonal thera! (Be-el 1 e-idence) Endocrine treatment should notnormall! commence until the oestrogen recetor status has been determined

one monitoring8 such as dual energ! xra! absortiometr! (&EKA) scanning8 should be a-ailable for atients ta7ingaromatase inhibitors8 and offered according to local guidelines $reatment for drug induced bone loss8 such as calcium su

lementation and bishoshonates *here necessar!8 should also be a-ailable

#c' C)emot)era*+

Ad>u-ant chemothera! rolongs diseasefree and o-erall sur-i-al in atients *ith earl! breast cancer:0

eseciall! in re

menoausal *omen *ith E% negati-e tumours (Be-el 1 e-idence) $he efficac! of chemothera! is greater in !ounger atientsEfficac! of chemothera! is seen in both E% ositi-e and negati-e breast cancer ,o*e-er in E% ositi-e disease treated b!

endocrine thera! the additional absolute benefit of chemothera! should be calculated $his is articularl! the case *here the ris7of recurrence is lo*8 E% exression is high M@or the atient is of older age *here the! are cometing causes of mortalit!

#d' Tareted t)era*ies

$raFtuFumab (hercetin) is a monoclonal antibod! to the ,E%2 recetor rotein "n ,E%2 ositi-e *omen8 ad>u-ant traFtuFu

mab (*hen combined *ith chemothera!) aroximatel! hal-es the ris7 of disease recurrence and death:18:2

(Be-el 1 e-idence),E%2 testing should be a-ailable for all ne* atients *ith in-asi-e breast cancer the test results must be a-ailable for discussion at

the


21/26

ARTICLE IN PRESS


SE$"O# 12C B"#"AB 6OBBOH '.

Earl! diagnosis and ad>u-ant treatments ha-e imro-ed the outloo7 for man! atients *ith breast cancer ,o*e-er8 aroortion of atients *ill still de-elo distant metastases and die of the disease $*othirds of all recurrences occur*ithin the first 4 !ears after treatment8 the fre3uenc! of e-ents decreasing *ith time

$here is no firm e-idence that earl! detection of local or s!stemic recurrence imro-es sur-i-al ,o*e-er man! breast

cancer atients see7 reassurance that the! are free of recurrence and that an! such recurrence *ill be detected at the earliestoortunit! $he lac7 of sur-i-al benefit for clinical follo* u has been documented in the ==%ecommended reast ancer

Sur-eillance Guidelines== adoted b! the American Societ! of linical Oncolog! (ASO)1

%andomised studies testingthe-alue of intensi-e follo* u suggest that there is little or no sur-i-al benefit accruing from intensi-e sur-eillance *ith multile

in-estigations108::

e:/

(Be-el 2 e-idence) ,o*e-er the ma>orit! of these studies *ere carried out 10e20 !ears ago *hen

man! of the current ne* drug regimes *ere not a-ailable 6urthermore in man! of the studies the follo* u *ould not beregarded as intensi-e b! toda!=s standards

A re-ious reort b! the #ational "nstitute for linical Excellence (#"E) recommends that routine hosital follo* uis discontinued after three !ears unless atients are *ithin clinical trials and that subse3uent follo* u should bemaintained in the communit! *ith raid access to the breast clinic -ia the reast are #urses in cases of susected

recurrence4,o*e-er the le-el of e-idence for this recommendation (ie8 discontinuing standard follo* u) is lo*

$he Association of reast Surger! at ASO has noted the abo-e reort and made the follo*ing recommendationsC

.atients on continuing acti-e treatment should be follo*ed u until such treatment has been comleted

.atients *ith E% ositi-e disease ma! need to be seen at lanned inter-als to discuss changes in thera!8 the so callede>so20090100/


22/26

ARTICLE IN PRESS


linical follo* u


$o ensure a))ro)riate clinical follo* u) of breast cancer Each breast unit should ha-e agreed local guidelines for clinical follo* u of atientsatients *ith breast cancer (including mammograhic sur-eillance) and mechanisms for the

raid rereferral of atients *ith susected recurrence

$o ensure ade3uate collection of outcome data on all Aroriate data management resources should be a-ailable to record follo* u andatients treated for breast cancer outcome data

$o ensure breast unit articiation in national audits All breast units should articiate in ongoing national audits such as the #,S reastScreening .rogramme audits8 the O5 audit and the Sloane .ro>ect

Ac7no*ledgements

He gratefull! ac7no*ledge the follo*ing for their assistance in the roduction of these guidelinesC ,ugh isho8harlie han8 "an 5on!enn!8 Julietta .atnic78 5ar7 Sibbering8 %oger Hat7ins8 John Hinstanle! (Hriting Grou) #igelundred8 Allan order8 Ste*art #icholson8 John %obertson8 #eil %othnie and the #ational ommittee of the Associationof reast Surger! at ASO for commenting on the drafted guidelines and Buc! &a-ies for assistance in their ublication



23/26

ARTICLE IN PRESS


%eferences

1.?ualit! assurance guidelines for surgeons in breast cancer screening #,SS. .ublication #o 20 1992

2.$he reast Surgeons Grou of the ritish Association of Surgical Oncolog! Guidelines for surgeons in the management of s!mtomatic breast disease inthe 'nited +ingdom Eur Sur !ncol199421(Sul A)C1N1

3.A *olic+ 4ramewor7 4or commissionin cancer services8 a re*ort b+ t)e E"*ert Advisor+ Grou* on Cancer to t)e C)ie4 ,edical !44icers o4

Enland and 3ales BondonC ,5SO 1994

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7.Earl! reast ancer $rialists= ollaborati-e Grou Effects of radiothera! and of differences in the extent of surger! for earl! breast cancer on localrecurrence and 14 !ear sur-i-alC an o-er-ie* of randomiFed trials Lancet 2004;;C20/N10;

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(2009)8 doiC10101;@>e>so20090100/


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#otes

Be-els of e-idenceC e-idence is graded 1 (deri-ed from randomiFed controlled trials e %$s)8 2 (obser-ational studies)and (rofessional consensus) $hese are broad categories and the 3ualit! of e-idence *ithin each categor! -aries *idel!$hus it should not be assumed that %$ e-idence (grade 1) is al*a!s more reliable than e-idence from obser-ational studies(grade 2)

$hese guidelines are ad-isor! and *ill be re-ie*ed in 2011
http://www.nice.org.uk/TA107http://www.nice.org.uk/TA107http://www.nice.org.uk/TA107http://www.nice.org.uk/TA107http://www.nice.org.uk/TA107http://www.nice.org.uk/TA107


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surgical aguidelines for the management of breast cancer

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