Genetic considerations
There are considerations for the management of patients with early breast cancer who are at high risk of breast cancer due to familial or genetic factors.
Recommendations and practice points are included relating to assessment of familial and genetic risk factors and referral for genetic counselling and testing, the treatment options for patients with identified gene mutations, and risk-reducing strategies. Many of the treatment options for patients with a known gene mutation are the same as for patients without a gene mutation, such as neoadjuvant and adjuvant chemotherapy and radiotherapy (except for patients with p53 gene mutation), whereas surgical treatment options vary. An option for follow-up surveillance imaging for premenopausal women with a gene mutation associated with breast cancer, is provided.
Lymphoedema
Lymphoedema is swelling caused by an accumulation of excess lymph fluid. It is a potential side effect after treatment for early breast cancer when lymph nodes are removed by surgery or damaged by radiotherapy and it can have a significant effect on quality of life for patients. At least 20% of breast cancer patients will develop lymphoedema.
Recommendations and practice points are included on the provision of information for patients on the risk of lymphoedema and minimising risk, ongoing assessment and management of patients at higher risk of lymphoedema, management of lymphoedema, including access to a lymphoedema therapist, and procedures on the treated side.
Reproductive and sexual health
Reproductive health considerations include avoiding pregnancy during active treatment of breast cancer due to the risk of congenital abnormalities, and the effects of some treatments on fertility. Recommendations and practice points are included on contraception for premenopausal women and pregnancy planning while receiving therapy for early breast cancer, and on fertility issues for women of childbearing age.
Breast cancer and its treatments can have a significant impact on sexual health and wellbeing due to potential psychological and physical side effects of surgical and medical treatments and associated changes in hormonal levels that can result in an early or acute menopause. Recommendations and practice points are included on the management of symptoms associated with reduced sexual health, and sexual dysfunction, and possible referral to a therapist.
Wellbeing and psychosocial care
Healthy lifestyle choices, such as a balanced diet, achieving and maintaining a healthy weight, regular physical activity, not smoking and limiting alcohol intake, can improved health and wellness and may reduce the risk of second and recurrent cancers. Exercise can improve the physical and emotional health and wellbeing of patients and helps counteract the adverse effects of breast cancer and its treatment.
Recommendations and practice points are included on healthy lifestyle advice for patients with early breast cancer, including advice on physical activity, not smoking, and achieving and maintaining a healthy weight.
Psychosocial care encompasses supportive care for the social, psychological, emotional, spiritual, and functional effects of cancer on patients. Patients may experience psychosocial effects such as anxiety and depression, emotional and psychological distress, fear of cancer recurrence, changes in their social relationships, and practical day-to-day demands. Psychosocial care needs can occur across the continuum of care.
Recommendations and practice points are included on assessing and managing psychosocial needs (such as depression and anxiety, fear of cancer recurrence, and return to work issues), referral to counselling or appropriate support services, and psychosocial care for particular groups such as pregnant women and patients at a higher risk of depression.
Older patients
Most breast cancer patients, particularly in an ageing population, are older adults. However, evidence is lacking for the treatment of older patients, partly because they are underrepresented in clinical trials – especially chemotherapy trials. The lack of evidence has led to a lack of evidence-based guidelines. The SIOG/EUSOMA source guideline for older patients used in this guidance, and the most recent comprehensive guideline specifically for breast cancer among older patients, was published in 2012.
There are specific considerations for the management of older patients with early breast cancer, such as biological age and life expectancy, complex comorbidities, risk of adverse and side events, and drug interactions.
Biological age or functional age should be considered rather than chronological age. Frailty should be regarded as a spectrum rather than binary. Treatment decisions are assisted by screening and if necessary, a full geriatric assessment. Data emphasise the need for multidisciplinary coordination in making individualised treatment recommendations for older patients. Collaborative geriatric and oncology management can optimise care.
Recommendations and practice points are included on the appropriate considerations for the management of older patients, treatment options, use of geriatric assessment including assessment of general health and functional status, and involvement of a geriatrician.
Younger or premenopausal women
Treatment decisions in young women should be made considering the biology of their breast cancer rather than by age alone. Treatment of younger or premenopausal women with early breast cancer however, does involve specific therapeutic considerations for systemic therapy due to the different hormonal status and milieu of a pre-menopausal woman and pregnancy should be avoided during active treatment due to the risk of congenital abnormalities. Young women also have a higher genetic cancer predisposition. Breast cancer treatments can reduce fertility and result in early menopause.
Recommendations and practice points are included on contraception for premenopausal women while on therapy for early breast cancer, fertility issues and fertility preservation (including consideration of referral to a fertility specialist) ovarian suppression and chemotherapy.
Pregnancy
Treatment for pregnant women with breast cancer is generally as closely aligned as possible to women with breast cancer who are not pregnant, however there are some specific treatment considerations.
Recommendations and practice points are included on the composition of the multidisciplinary team for pregnant women with breast cancer and treatment considerations including for sentinel lymph node biopsy and lymphatic mapping, timing of chemotherapy, and radiation therapy. There is a practice point on treatment contraindications while breastfeeding.
Particular attention should be paid to each woman’s preferences and psychosocial needs due to the higher likelihood of distress that pregnant women with breast cancer may have.
