Guidance

Key priorities for implementation

Key priorities for implementation

Diagnosis and assessment

  • Positron emission tomography fused with computed tomography (PET-CT) should only be used to make a new diagnosis of metastases for patients with breast cancer whose imaging is suspicious but not diagnostic of metastatic disease. [2009]

  • Assess oestrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status at the time of disease recurrence if receptor status was not assessed at the time of initial diagnosis. In the absence of tumour tissue from the primary tumour, and if feasible, obtain a biopsy of a metastasis to assess ER and HER2 status. [2009]

Systemic disease-modifying therapy

  • Offer endocrine therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer. [2009]

  • For patients with advanced breast cancer who are not suitable for anthracyclines (because they are contraindicated or because of prior anthracycline treatment either in the adjuvant or metastatic setting), 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 (whichever was not used as second-line treatment). [2009]

  • For patients who are receiving treatment with trastuzumab[3] 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. [2009]

Supportive care

  • Healthcare professionals involved in the care of patients with advanced breast cancer should ensure that the organisation and provision of supportive care services comply with the recommendations made in Improving outcomes in breast cancer: manual update (NICE cancer service guidance [2002]) and Improving supportive and palliative care for adults with cancer (NICE cancer service guidance [2004]), in particular the following two recommendations:

    • 'Assessment and discussion of patients' needs for physical, psychological, social, spiritual and financial support should be undertaken at key points (such as diagnosis; at commencement, during, and at the end of treatment; at relapse; and when death is approaching).'

    • 'Mechanisms should be developed to promote continuity of care, which might include the nomination of a person to take on the role of "key worker" for individual patients.' [2009]

Managing complications

  • A breast cancer multidisciplinary team should assess all patients presenting with uncontrolled local disease and discuss the therapeutic options for controlling the disease and relieving symptoms. [2009]

  • Consider offering bisphosphonates to patients newly diagnosed with bone metastases, to prevent skeletal-related events and reduce pain. [2009]

  • Use external beam radiotherapy in a single fraction of 8Gy to treat patients with bone metastases and pain. [2009]

  • Offer surgery followed by whole brain radiotherapy to patients who have a single or small number of potentially resectable brain metastases, a good performance status and who have no or well-controlled other metastatic disease. The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1. [2009]


[3] Recommendations on the use of trastuzumab are covered by Guidance on the use of trastuzumab for the treatment of advanced breast cancer (NICE technology appraisal guidance 34; 2002), which will be updated.

  • National Institute for Health and Care Excellence (NICE)