Lymphoedema
Lymphoedema – Risk minimisation #1 (Recommendation)
For patients who have had treatment for breast cancer, give advice on skin care and how to prevent and manage infection that may cause or exacerbate lymphoedema.
How this guidance was developed
This recommendation was adopted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Give advice’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was accepted with minor rearrangement of the wording, with no changes to the meaning or tone of the source recommendation.
Lymphoedema – Risk minimisation #2 (Recommendation)
When informing patients with breast cancer about the risk of developing lymphoedema or breast or chest wall oedema, advise them of the importance of using the treated arm in daily activities and of regular participation in physical activities and maintenance of a healthy weight to minimise the risk of lymphoedema/oedema.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Advise’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The NICE Committee noted good evidence showing no increased risk of lymphoedema associated with maintaining exercise levels after axillary intervention. The source recommendation was simplified by adding ‘breast/chest wall oedema’ and the tone of the source recommendation was changed by replacing the double-negative phrase ‘do not need to restrict their physical activity’. The maintenance of a healthy weight was also included.
Lymphoedema management – Procedures on the treated side (Recommendation)
Low risk medical procedures (such as injections, blood tests, or intravenous administration of medicines) can be performed on the arm of the treated side if needed, as such procedures will not cause or worsen lymphoedema. In patients with lymphoedema, blood pressure monitoring on the arm of the treated side should depend on clinical need.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted in September 2017. The strength of the recommendation could not be determined from the wording and is more of an evidence statement. The adaption clarified that low risk medical procedures can be performed on the affected side without fear of causing or worsening lymphoedema. It was acknowledged that there is insufficient evidence to support or not support blood pressure monitoring of the treated arm, hence the decision should be based on clinical need.
Lymphoedema management – Access to a lymphoedema therapist (Recommendation)
Patients who have been treated for breast cancer who develop lymphoedema should have access to a lymphoedema therapist.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted in July 2008 and used wording (‘Ensure’) indicative of a strong recommendation (using SIGN methods) by the source guideline authors. The recommendation was adapted by removing the word ‘rapid’ as rapid access is not always feasible, and by using language applicable to the Australian health care context.
Menopausal symptoms
Menopausal symptom management – Contraindications (Recommendation)
Discuss the risks and benefits of therapies for managing menopausal symptoms (hot flushes, night sweats and vaginal dryness) associated with breast cancer treatments, noting that all forms of systemic menopausal hormonal therapy (MHT) including oestrogen-only, combined oestrogen and progestogen, tibolone, and compounded or bioidentical hormones are contraindicated in women with a personal history of breast cancer.
How this guidance was developed
This recommendation was adapted from the KCE 2013 guidelines (Belgium) and the CA 2016 guidelines (Australia). The KCE 2013 recommendation was based on a systematic review of the evidence conducted to January 2010 and was graded ‘strong’ (using GRADE methods) by the source guideline authors. The recommendation from CA 2016 relates to exceptional cases where MHT can be considered and how the benefits and risks should be discussed. It was based on a systematic review conducted to January 2014 and was graded 'B' (using NHMRC methods) by the source guideline authors. The two recommendations were merged, and acknowledgement was made to more recent evidence that a personal history of breast cancer is now considered to be an absolute contraindication to MHT.
The third source recommendation is incorporated in relation to bioidentical hormones also being contraindicated. This CA 2016 recommendation was based on a systematic review conducted to January 2014 and was graded 'C' (using NHMRC methods) by the source guideline authors.
Menopausal symptom management – Cognitive behavioural therapy (Recommendation)
Consider first-line treatment with cognitive behavioural therapy (CBT) delivered in person or online for the management of moderate to severe hot flushes or night sweats and sleep disturbance in women with a history of breast cancer.
How this guidance was developed
This recommendation was adapted from the CA 2016 guidelines for the management of menopausal symptoms in women with a history of breast cancer (Australia). The source recommendation was based on a systematic review of the evidence conducted to 2015 and was graded 'C’ (using NHMRC methods) by the source guideline authors. The source recommendation was simplified to reflect the overarching principle of the source guidelines of offering first-line treatment with non-systemic therapies. The adapted recommendation acknowledged the 2015 Position Statement of the North American Menopause Society, and more recent RCT evidence, that CBT is now accepted as first line treatment for sleep disturbance, and it can be delivered effectively in person or online.
Menopausal symptom management – Non-endocrine systemic therapies (Recommendation)
Consider second-line treatment with non-endocrine systemic therapies (venlafaxine, desvenlafaxine, paroxetine, escitalopram, clonidine, or gabapentin) at doses shown to be effective in the management of moderate to severe hot flushes or night sweats in women with a history of breast cancer. Women treated with any of these drugs should be monitored for the development of adverse effects which may include sexual dysfunction, gastrointestinal symptoms, anxiety, sleep disturbance, or in rare cases suicidal ideation. Be aware that paroxetine should be avoided in women treated with tamoxifen.
How this guidance was developed
This recommendation was adapted from the CA 2016 guidelines for the management of menopausal symptoms in women with a history of breast cancer (Australia). Six source recommendations (one for each pharmaceutical treatment) were merged and simplified by removing prescribing details. All six source recommendations were based on a systematic review conducted to 2015: five (venlafaxine, paroxetine, escitalopram, desvenlafaxine and clonidine) were graded ‘A' or 'B' using NHMRC methods and the one for gabapentin was graded 'C' using NHMRC methods by the source guideline authors. A potential NICE (UK, 2009, updated 2018) source recommendation was noted indicating that selective serotonin reuptake inhibitor antidepressants should be avoided in women taking tamoxifen. Paroxetine, fluoxetine, and buproprion, are strong CYP2D6 inhibitors.
Menopausal symptom management – Sleep disturbance (Recommendation)
In breast cancer patients experiencing sleep disturbance due to vasomotor symptoms and that is impacting on their quality of life, consider the second-line use of non-endocrine systemic therapies (desvenlafaxine, paroxetine, gabapentin) at doses shown to be effective in the management of sleep disturbance due to vasomotor symptoms. Be aware that paroxetine should be avoided in women treated with tamoxifen.
How this guidance was developed
This recommendation was adapted from the CA 2016 guidelines for the management of menopausal symptoms in women with a history of breast cancer (Australia). Three source recommendations (one for each pharmaceutical treatment) were merged and simplified by removing unnecessary details. All three source recommendations were based on a systematic review conducted to 2015: the Desvenlafaxine source recommendation was graded ‘B’ (using NHMRC methods) and the paroxetine and gabapentin source recommendations were graded ‘C’ (using NHMRC methods) by the source guideline authors.
Menopausal symptom management – Complementary or alternative therapies (Practice Point)
Advise patients that there is negative or insufficient evidence of the effectiveness of other complementary or alternative therapies for the management of hot flushes, night sweats or vaginal dryness.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. The 2015 Position Statement of the North American Menopause Society is acknowledged.
Reproductive and sexual health
Sexual intimacy concerns (Recommendation)
Ask patients about concerns with sexual intimacy, and refer for further therapy, if appropriate.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by replacing ‘problems’ with ‘concerns’, and by removing 'primary care clinician' as this aspect of care could be addressed by other members of the cancer care team, as well as GPs.
Vulvovaginal symptom treatments #1 (Practice Point)
In women with a history of breast cancer who have vaginal dryness, offer first-line treatment with non-alcohol based vaginal lubricants during sexual activity. Consider topical lidocaine treatments to the vulvovaginal area for women experiencing pain with sexual activity.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process. The practice point was informed by a source recommendation in the ACS/ASCO 2016 guidelines (US) that was designated as ‘Expert Opinion’ by the source guideline authors. This recommendation was not adopted or adapted because it was considered confusing, and vaginal moisturisers have not been shown to be effective. Use of topical lidocaine in women with a history of breast cancer to reduce dyspareunia has been successfully trialled in a phase II, randomised, placebo-controlled study.
Vulvovaginal symptom treatments #2 (Recommendation)
In women with a personal history of breast cancer who have persistent vulvovaginal symptoms that are unresponsive to non-hormonal treatments, consider second-line treatment with vaginal oestrogens (low dose vaginal oestradiol, or vaginal oestriol).
How this guidance was developed
This recommendation was adapted from the CA 2016 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2014 and was graded 'C’ (using NHMRC methods) by the source guideline authors. The source recommendation was adapted by removing some of the detail.
Sexual function – Exogenous testosterone (Recommendation)
Exogenous testosterone is not recommended as a treatment to improve sexual function in women with a personal history of breast cancer as the efficacy and long-term safety after breast cancer has not been established.
How this guidance was developed
This recommendation was adopted from the CA 2016 guidelines (Australia). The source recommendation was based on a systematic review of the evidence conducted to January 2014 and was graded 'C’ (using NHMRC methods) by the source guideline authors. The source recommendation was accepted with no changes.
Infertility after treatment – Specialist referral (Recommendation)
Patients of childbearing age who experience infertility after treatment for breast cancer should be referred to a specialist in reproductive endocrinology and infertility as soon as possible.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted to make it clearer that the recommendation is for patients intending to become pregnant after breast cancer treatment.
Fatigue and sleep disorders
Fatigue assessment (Recommendation)
Assess all patients with breast cancer for fatigue and advise patients on the importance of good sleep hygiene practices.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by removal of reference to ‘primary care clinicians’, as all health professionals involved in the care of a patient could take responsibility for this aspect of care.
Fatigue management and referral (Recommendation)
Offer therapy or referral, as appropriate, for factors that may impact on or cause fatigue (e.g. depression, sleep disturbance, pain, anaemia, lymphoedema, thyroid or cardiac dysfunction). For those patients who do not have an otherwise identifiable cause of fatigue, offer referral to appropriate assessment and treatment services (such as a psychologist).
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to April 2015 and was not graded by the source guideline authors. The source recommendation was adapted by adding in lymphoedema as a cause of fatigue, and reference to referral to appropriate assessment and treatment services.
Fatigue and physical activity (Practice Point)
In patients with breast cancer who are experiencing fatigue, encourage physical activity as exercise counteracts the adverse effects of cancer and its treatment.
How this guidance was developed
This practice point was developed using an expert consensus process. The practice point was informed by the COSA Position Statement on Exercise in cancer care (2020).
Pain
Pain assessment (Practice Point)
Assess for pain and contributing factors with the use of a simple pain scale and comprehensive history of the patient’s condition. Be aware of the importance of assessing ongoing and persistent or new pain and consider the possibility of local recurrence.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process, informed by an ungraded recommendation in the ACS/ASCO 2016 guidelines.
Treatment-related pain – Management (Recommendation)
Where treatment-related pain is present, offer interventions such as paracetamol and non-steroidal anti-inflammatory drugs. Consider referral to a specialist practitioner (e.g. lymphoedema therapist, occupational therapist, or pain specialist) as appropriate, depending on the underlying cause of the pain.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendations were based on a systematic review of the evidence conducted to April 2015 and were not graded by the source guideline authors.
Treatment-related arthralgia – Management (Practice Point)
In patients with breast cancer who are experiencing arthralgia, encourage physical activity/exercise as exercise reduces musculoskeletal symptoms. If exercise or NSAIDs are unsuccessful, consider changing to a different aromatase inhibitor, use of duloxetine, or switching to tamoxifen.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed in response to stakeholder feedback, to support women in adhering to endocrine therapy.
Treatment-related peripheral neuropathy – Assessment and management (Recommendation)
Assess for peripheral neuropathy in relation to chemotherapy by asking patients about their symptoms, specifically symmetrical numbness and tingling in their hands and/or feet, and the characteristics of the symptoms. Physical activity and/or duloxetine may be helpful in the treatment of peripheral neuropathic pain, numbness, and tingling. Be aware that asymmetrical numbness of the hands may be due to carpal tunnel syndrome, which is more common in women with breast cancer on endocrine therapy and will require different management.
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). Three source recommendations were merged, and language was used that is applicable to the Australian healthcare context, including making it action-specific, rather than clinician-specific. The source recommendations were based on a systematic review conducted to April 2015 and were not graded by the source guideline authors. The source recommendations were adapted by adding specificity regarding the importance of differentiating between peripheral neuropathy and carpal tunnel syndrome.
Cognitive impairment
Cognitive impairment – Assessment and management (Recommendation)
If cognitive impairment in association with breast cancer or its treatment is suspected, assess for and treat reversible contributing factors (e.g. thyroid dysfunction), discuss coping strategies, and offer referral to an appropriate health professional (geriatrician, neurologist, psychiatrist or psychologist) experienced in the assessment and management of cognitive impairment.
Useful Links
How this guidance was developed
This recommendation was adapted from the ACS/ASCO 2016 guidelines (US). The source recommendations were based on a systematic review conducted to April 2015 and were not graded by the source guideline authors. In the adaptation of the source recommendations it was made clear that the recommendation relates to cognitive impairment that can arise as a consequence of the cancer and/or its treatment, i.e. cancer-related cognitive impairment, particularly from chemotherapy.
