Psychosocial assessment - General (Practice Point)
Pay attention to the emotional needs of the person diagnosed with breast cancer and undertake psychosocial screening as soon as possible after breast cancer diagnosis and at the commencement of any new treatment. Use a validated and reliable measure that features reportable scores that are clinically meaningful, with established cut-offs.
How this guidance was developed
This practice point was developed using an expert consensus process. A potentially relevant ‘strong’ (GRADE) source recommendation was identified from the KCE 2013 guidelines (Belgium) that recommended psychological support. However, this KCE recommendation was not adopted or adapted as it was considered too narrow in scope and did not account for the timing or approach to psychosocial screening.
Psychosocial assessment - High risk (Recommendation)
A detailed psychosocial assessment should be undertaken for patients at a higher risk of depression, e.g. patients with a history of mental health issues, patients with caring responsibilities, patients under financial stress, young patients, and those with multiple stressors.
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 simplified, and language used that is applicable to the Australian health care context.
Psychosocial assessment – Referral (Recommendation)
If signs of distress, depression, or anxiety are present, consider offering patients referral to counselling and/or appropriate psycho-oncology and mental health resources as clinically indicated.
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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 simplified, and language used that is applicable to the Australian health care context.
Genetic risk assessment (Recommendation)
All patients with breast cancer should be assessed at or around the time of diagnosis for familial and genetic risk factors as indicated in current eviQ guidelines, which include relevant pathogenic variants in adult blood relatives, gender, ancestry, breast cancer characteristics, and personal and family cancer history.
How this guidance was developed
This recommendation was adapted from two source guidelines: the ASCO 2013 (US) and the ACS/ASCO 2016 guidelines (US). The ACS/ASCO (2016) source recommendation is based on a systematic review of the evidence conducted to April 2015 and the ASCO (2013) source recommendation is based on a systematic review of the evidence conducted to June 2012. Neither were graded by the source guideline authors. The source recommendations were merged and then separated (see recommendation 'Genetic counselling and testing – Referral'). Reference to the eviQ guidelines was added as they are current and relevant to the Australian context. Details about the timing of risk assessment were specifically added.
This recommendation aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 1.
Genetic counselling and testing – Referral (Recommendation)
In accordance with eviQ guidelines, patients suspected of having high familial or genetic cancer risk should be referred to a family cancer clinic for genetic counselling and genetic testing as appropriate.
How this guidance was developed
This recommendation was adapted from two source guidelines: the ASCO 2013 (US) and the ACS/ASCO 2016 guidelines (US). The ASCO (2016) source recommendation is based on a systematic review of the evidence conducted in April 2015 and the ASCO (2013) source recommendation is based on a systematic review of the evidence conducted in June 2012. Neither were graded by the source guideline authors. The source recommendations were merged and then separated (see recommendation 'Genetic risk assessment'). Reference to genetic counselling and testing was included, and the term ‘family cancer clinics’ was used to improve applicability to the Australian health care context.
This recommendation aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 1.
Fertility considerations – Referral (Practice Point)
Discuss fertility issues and the implications of premature menopause with all premenopausal women. Arrange early referral to a fertility specialist to maximise the opportunity for consideration of fertility preservation if appropriate and feasible.
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. Development of this guidance was informed by a source recommendation in the EUSOMA 2012 recommendations for breast cancer in young women (Europe) based on a non-systematic review of the evidence and that was graded as ‘low’ (using AHRQ methods) by the source guideline authors. It is also informed by a source recommendation in the ESO-ESMO 2017 and 2020 guidelines for breast cancer in young women (Europe) graded as ‘Expert Opinion’ by the source guideline authors, and which specifically indicates counselling before the onset of systemic therapy.
This recommendation aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 3.
Pregnancy considerations (Recommendation)
Premenopausal women should be counselled regarding the risk of becoming pregnant while on chemotherapy, endocrine therapy, anti-HER2 therapy, or during radiation therapy, even in the presence of amenorrhoea.
How this guidance was developed
This recommendation was adopted from the ESO-ESMO 2017 guidelines for breast cancer in young women (Europe), and which remained unchanged in the 2020 updated guidelines. The source recommendation is based on a non-systematic review of the evidence (date was not reported) discussed by the source guideline authors in November 2016 and October 2018 and graded ‘strong’ (using ACCP/Adapted Infectious Diseases Society of America-United States Public Health Service Grading System methods). The source recommendation was adapted to include 'radiation therapy' as a risk factor and minor stylistic changes were made.
Contraception considerations #1 (Recommendation)
Discuss and offer barrier contraceptive options (condoms or diaphragms, a copper intrauterine device, or surgical options) for premenopausal women with breast cancer, noting that systemic hormonal contraception is contraindicated irrespective of disease subtype.
How this guidance was developed
This recommendation was adapted from two source guidelines: the ACOG 2012 guidelines (US) and the ESO-ESMO 2017 guidelines (Europe). The ACOG source recommendation was based on a non-systematic review of the evidence conducted to November 2011. The ESO-ESMO source recommendation is based on a non-systematic review of the evidence review (the date of the review was not reported) discussed by the source guideline authors in November 2016 and graded as ‘Expert Opinion’ by the guideline authors. The ESO-ESMO recommendation was unchanged in the 2020 update (discussed October 2018).
Contraception considerations #2 (Practice Point)
Premenopausal women should be advised not to use a levonorgestrel-releasing intra-uterine device (LNG-IUD) and to use alternative non-hormonal contraception, as the safety of the LNG-IUD among women with breast cancer has not been determined.
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 wording is informed by the narrative in the two most recent ESO-ESMO 2017 and ESO-ESMO 2020 guidelines based on a non-systematic review of the evidence; as well as the product information advice. Consideration was given to wording around potential use of a levonorgestrel-releasing intra-uterine device (LNG-IUD) in women on tamoxifen as it provides effective contraception and reduces tamoxifen-induced endometrial changes (incidence of benign polyps and endometrial hyperplasia), as long as the patient was made aware of the uncertainty surrounding the effect of the LNG-IUD on breast cancer recurrence. However, the lack of clear data on breast cancer recurrence or breast-cancer related deaths associated with its use, combined with the product information contraindication, was considered sufficient to currently recommend against its use. It is noted that some women may choose to use this method of contraception but this choice should be fully informed of the potential risks.
Geriatric assessment (Recommendation)
A screening geriatric assessment is a reasonable first step in identifying patients who may benefit from an extended comprehensive geriatric assessment.
How this guidance was developed
This recommendation was adopted from the SIOG/EUSOMA 2012 (Europe) guideline for the management of elderly patients with breast cancer. The source recommendation was based on a systematic evidence review to June 2010 and was not graded by the source guideline authors.
Lymphoedema risk assessment and referral (Practice Point)
Patients at higher risk of lymphoedema (e.g. those in whom axillary clearance or axillary radiation therapy is planned, or patients with lymphatic insufficiency) should be referred to a lymphoedema therapist for assessment prior to breast cancer treatment, and for regular monitoring after breast cancer treatment. Bioimpedance measurements may be part of the clinical assessment.
How this guidance was developed
This practice point was developed using an expert consensus process. The practice point was informed by two source recommendations, one from the KCE 2013 guidelines (Belgium) that was graded ‘Strong’ using GRADE methods by the source guideline authors, and one from NICE 2018 guidelines (evidence review to 2007, not updated in 2017) that used wording ('Ensure') indicative of a strong recommendation. The practice point was also informed by the principles of lymphoedema identification and management from the NSW Health, Agency for Clinical Innovation (2018).
Cardiac risk assessment - Recommendation
A baseline cardiac risk assessment, including an echocardiogram, should be undertaken for patients whose treatment will include chemotherapy (especially anthracyclines) or HER2 therapy (especially trastuzumab) or left-sided radiation therapy.
How this guidance was developed
This recommendation was adapted from two source recommendations: one from the ASCO (2017) guideline on prevention and monitoring of cardiac dysfunction (US) based on a systematic review of the evidence conducted in February 2016 and graded ‘strong’ (using ASCO methods) by the source guideline authors; and one from the AHS (2015) guideline (Canada) which was based on a systematic review of the evidence to April 2013 and was not graded. It is also supported by the recent ESMO (2020) consensus recommendations on cardiac disease management in cancer patients, based on a systematic evidence review to June 2018 with the relevant recommendation graded ‘A’ using the Infectious Diseases Society of America-United States Public Health Service Grading System.
Further specific recommendations for baseline cardiovascular assessment are included on the ESMO (2020) guidelines and include: the potential for making baseline measurement of cardiac biomarkers for high risk patients (with pre-existing significant cardiovascular disease) and those receiving high doses of cardiotoxic chemotherapy such as anthracycline; and, in patients scheduled to undergo anticancer therapy associated with HF or LVD, baseline evaluation of LVEF and diastolic functioning according to comprehensive imaging practice is recommended.
Use of potentially cardiotoxic therapies (Practice Point)
Avoid or minimise the use of potentially cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes.
How this guidance was developed
This practice point was adopted from the ASCO 2017 (US) guideline on prevention and monitoring of cardiac dysfunction (US) based on a systematic review of the evidence conducted to February 2016. The source recommendation was indicated to be 'consensus-based' rather than 'evidence-based' and the strength of the recommendation was graded ‘strong’ (using ASCO methods) by the source guideline authors.
