A protocol for the management of breast cancer developed by the multidisciplinary oncology team at University of Nigeria Teaching Hospital, fully adapted to our environment

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University of Nigeria Teaching Hospital
Bre st Cancer
Management Protocol
May 2017
1st Edition

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FORWARD
This first edition of the protocol for management of breast cancer at the
University of Nigeria Teaching hospital Enugu is a dream come true. It is a
collective effort of all the units involved in the multidisciplinary management
of breast cancer in our hospital. This edition takes into account the standard
guidelines on the management of breast cancer like the NCCN guideline,
ASCO recommendations and the ESMO guideline and integrates our
local circumstance to modify our treatment approach to breast cancer. It
is a home grown treatment guideline that all of us in the Multidisciplinary
breast cancer management can claim as our own. I therefore have no doubt
that Oncology specialists in our hospital and the neighbouring institutions
will find it a very workable document to guide them in their management
of breast cancer. It covers most aspects of the clinical management of the
disease, from screening to end stage palliative care. The first part of the
presentation shows the units and their job descriptions while the last part
deals with the actual management of disease from diagnosis at presentation
to palliative care for terminal disease. The existing local limitations of care
especially as it concerns cancer management in the South Eastern and
South South Nigeria were taken into consideration in the management
approach documented here. We accept that it is not a perfect document
but this initial effort will surely lead to improvements as we get comments
from the end users of this document. I recommend it very highly as a hand
book for oncology professionals working in any part of Nigeria.
Thank you
Professor Ezeome Emmanuel R –MBBS, FWACS
Director, UNTH Oncology Center
Chairman Faculty of Surgery WACS

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PREFACE
In the last 2 decades, the global incidence of breast cancer has increased
significantly. However, the developed world has recorded a slower rate of
increase in the last few years while the increase seems to be more rapid in
the developing world. Although breast cancer is thought to be a disease
of the developed world, almost 50% of breast cancer cases and 58% of
deaths occur in less developed countries (GLOBOCAN 2008). This trend
is a threat to developing nations with health systems that are ill-equipped
to deal with complex and expensive cancer treatments. Nigeria is acutely
caught up in this dilemma. With many sociocultural issues affecting the
average citizen’s health seeking behavior and our poor health system, it is
no wonder that most of our patients with breast cancer present late when
treatment options are limited, expensive and often yield poor outcomes.
The pattern of presentation at UNTH mirrors the national picture of
advanced disease which is often challenging. A desire to change this gloomy
picture and improve our survival indices birthed this guideline. There is
certainly no quick fix that would improve this grim picture but rather a more
holistic approach taking into consideration every aspect of the cancer care
continuum. Thus, in addition to breast awareness campaigns and organized
screening programmes, there must be a concerted effort to standardize
treatment protocols, remove institutional bottlenecks and improve the
referral system within and outside our hospital. A team approach involving
all key personnel in the management of breast cancer is standard practice.
As a comprehensive cancer center with referrals from the entire South East
and South South regions, our goal is to offer comprehensive cancer care
services across the cancer care continuum from public health awareness
campaigns and provision of screening services all the way to palliative care
and survivorship. The treatment options available for breast cancer at

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our institution has been harmonized and standardized in line with global
best practices. Many guidelines and publications were consulted in the
development of this document. We systematically went through these
resource materials and identified that which could be implemented in
our institution considering our available infrastructure.
The document is practical with 7 sections highlighting portions of the
cancer care continuum. Section one is the introduction and background
study while section two depicts our activities and action plans aimed
at creating awareness of breast cancer and the screening options
available to the public. Sections three, five and six show outlined
algorithms for diagnosis, treatment and palliative care while sections
four and seven highlight activities of our patient navigation unit and
survivorship programme.
The following units/departments were involved in the development of
this document - Radiology, Pathology, Surgical Oncology, Radiation
Oncology, Pain and Palliative Care Unit, Excercise Immunology/
Palliative unit of Physiotherapy Department, Medical Social
Services, Oncology Nursing Services and Oncology Pharmacy. Their
contributions are duly acknowledged.
Dr Lasebikan Nwamaka MBBS, FMCR
CONSULTANT, RADIATION AND CLINICAL ONCOLOGY UNTH
Email: amakalasebikan@gmail.com

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ACRONYMS
BSE- breast self examination
BCS- breast conserving surgery
CBE- clinical breast examination
DCIS- ductal carcinoma in situ
LCIS- lobular carcinoma in situ
CSO- civil society organisation
NGO- non governmental organization
pCR- pathological complete response
SOP- surgical out patient

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ACKNOWLEDGEMENTS
On behalf of the entire members of the UNTH BREAST CANCER PROTOCOL
DEVELOPMENT TEAM we are immensely grateful to the management of
UNTH – particularly the CMD Dr C.C. Amah and the CMAC Dr O. Onodugo
for their support in the production of this manual.
Special thanks go to ROCHE PHARMACEUTICALS for their unflinching
dedication to the success of this project.
To all members of the various subcommittees and their Chairs- Prof. I.J.
Okoye, Prof E.R Ezeome, Prof M. Nzegwu, Dr. K. Nwankwo, Dr T. Onyeka,
Dr. Olusiina, Dr. Ukaekwe, Dr Ezeofor, Dr Iloanusi, Dr. Dim, Dr Ilo, Dr Ede,
Dr Okwor, Mrs Obidiebube, Mrs Chigbo PT, Pharm (Mrs) Echendu and all
the contributors we are grateful for your tenacity and commitment to see
this project through. Especially grateful to Prof Okoye, Prof Ezeome and Dr
Nwankwo for their invaluable contributions.
Dr Lasebikan Nwamaka
For UNTH BREAST CANCER PROTOCOL DEVELOPMENT TEAM

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SUBCOMMITTEES MEMBERS CHAIR
Prevention/
screening/navigation
Prof Okoye
Dr Olusina
Dr Iloanusi
Dr Dim
Dr Ilo
Dr Okwor
Dr Nwankwo
Dr Udeh
Mrs Obidiebube
Mrs Chigbo PT
Dr Lasebikan
PROF OKOYE
Diagnostics Prof Nzegwu
Dr. Olusina
Dr. Ukaekwe
Prof Okoye
Dr Ezeofor
Dr Iloanusi
Dr. Dim
Prof Ezeome
Dr Ede
Dr Nwankwo
Dr Lasebikan
PROF EZEOME

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Treatment Prof Ezeome
Dr Nwankwo
Dr Ilo
Dr Okwor
Dr Ede
Mrs Chigbo PT
Pharm (Mrs) Echendu
Mrs Obidiebube
Dr Lasebikan
DR NWANKWO
Palliative care
Patient support
Services/Group
Dr Onyeka
Dr Ilo
Dr Okwor
Pharm(Mrs) Echendu
Mrs Obidiebube
Mrs Chigbo PT
Dr Lasebikan
DR ONYEKA
Stratergy Prof Okoye
Prof Ezeome
Prof Nzegwu
Dr Udeh
Pharm (Mrs) Echendu
Dr Lasebkan
PROF EZEOME

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CONTRIBUTORS
Dr Agu Orah Chinenye
Dr Chukwulebe Ozor Ebele
Dr. Nwajiobi Uwaoma Nwamaka
Dr Dilibe Okoroafor Ann
Dr. Enemuo Ezeagagwu Dorathy
Dr. Osuagwu Dr Agnes Anaraodo
Dr Onumaegbu Dr Shiweobi
Dr Okwesili Dr Ugwu
Dr Nnakenyi Chinyere Ndam
Dr Okafor Christiana Obasi
Pharm Anyaebosi Obianuju Dr Okwara Blasius
Dr Uko
Nnadi Casmir
Ogbona Cyril

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TABLE OF CONTENTS
FORWARD
PREFACE
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
EXECUTIVE SUMMARY
SECTION ONE- INTRODUCTION
SECTION TWO-PREVENTION AND SCREENING ACTIVITIES
SECTION THREE- DIAGNOSIS
SECTION FOUR- PATIENT NAVIGATION AND BREAST CANCER
SUPPORT GROUP
SECTION FIVE - TREATMENT
SECTION SIX - PALLIATIVE CARE
SECTION SEVEN - SURVIVORSHIP
REFERENCES
APPENDIX A- UNTH CHEMOTHERAPY CONSENT FORM

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EXECUTIVE SUMMARY
Guidelines for Breast Cancer Management at UNTH, Enugu
THIS PRACTICE ALGORITHM HAS BEEN SPECIFICALLY
DEVELOPED FOR UNTH USING A MULTIDISCIPLINARY
APPROACH AND TAKING INTO CONSIDERATION
CIRCUMSTANCES PERCULAR TO UNTH, INCLUDING THE
FOLLOWING: UNTH’S SPECIFIC PATIENT POPULATION;
UNTH’S SERVICES AND STRUCTURE; AND UNTH’S CLINICAL
INFORMATION. MOREOVER, THIS ALGORITHM IS NOT
INTENDED TO REPLACE THE INDEPENDENT MEDICAL OR
PROFESSIONAL JUDGMENT OF PHYSICIANS OR OTHER HEALTH
CARE PROVIDERS.
Goal: Improving outcome of breast cancer
Key Recommendations
Multidisciplinary team work
All patients with breast cancer should be managed by multidisciplinary
teams. Multidisciplinary teams should constantly review how they might
improve efficiency and outcome.
Minimizing delay
No patient should wait more than four weeks for definitive treatment or
supportive intervention.
All patients should have their treatment planned following the treatment
guidelines and evidenced based standard best practices.

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Follow-up
The primary aim of clinical follow-up should be to identify and treat local
recurrence and adverse effects of therapy not to detect metastatic disease
in asymptomatic women.
Integration of palliative care services should be within 8 weeks of contact.
All patients should be encouraged to join the breast cancer support group.

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SECTION ONE
INTRODUCTION
Background
Incidence, mortality and prevalence
• The incidence of breast cancer has progressively increased in many
countries and it has become one of the leading causes of cancer
deaths in Nigeria. It represents 12% of all new cancers cases and 25%
of all cancers in women
• Breast Cancer is the most common and most lethal cancer in Nigeria
with an estimated 27,304 new cases in 2012 and projected to rise to
29,049 by 2015. This is likely a marked under-estimation since cancer
registration in Nigeria as a whole, is mainly hospital-based and
incomplete. Estimates from two population based cancer registries
suggest even higher rates. Breast cancer is a disease for which there is
effective screening and a high probability of cure when it is detected
early. The greatest challenge with breast cancer management in
Nigeria, as in most LMICs, is late presentation. This results in limited
and more expensive treatment options often with poorer outcomes.
Mortality rates are very high in our locality with approximately 13,960
deaths annually.
Risk factors
The risk factors for breast cancer are very complex. Genetic and
environmental factors have been implicated. Lifestyle modification has
been found to play a role in reducing some established risk factors and thus
the promotion of this is vital in primary prevention with a view to reducing
the incidence and subsequent mortality and morbidity associated with
breast cancer.

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Screening, diagnosis and treatment
Hitherto, there has been no established screening service operational
at UNTH nor is there an established pathway following screening and a
positive result. UNTH has a multidisciplinary tumour board and routinely
holds meetings to discuss patient diagnosis and treatment options.
Palliative care services are routinely offered to patients but psychosocial
support is lacking and needs to be developed. There is a social support
group that tries to meet the needs of the more indigent patient. This
service needs to be coordinated to reach out to more beneficiaries. There is
a breast cancer support group that routinely meets and provides a forum of
interaction between newly diagnosed breast cancer patients and survivors.

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SECTION TWO
PREVENTION and SCREENING
Mandate
A comprehensive cancer care center should provide public education
outreach programmes on cancer prevention and screening with special
attention to the needs of the underserved population.
KEYS AREAS OF IMPLEMENTATION
To provide public education and outreach programmes on breast cancer
prevention and screening with special attention to the needs of the
underserved population.
To create activities that will increase awareness in the target population,
promote healthy lifestyle modification, promote best practices in the health
sector and ultimately improve quality of care
To screen at least 70% of the normal risk population for breast cancer
within the catchment area covered by the population based cancer registry
domiciled at UNTH within a 2 year period (using CBE and mobile USS)
To reduce mortality and cost of treatment of breast cancer by increasing
early detection through education, communication, advocacy and improving
standard of care
Strategies
• Production of educational tools, fliers for distribution at strategic
points. Educational materials produced will cover the following
topics in English and Igbo languages.
• Anatomy of female breast, diagrammatic representation. The rationale
for this being to facilitate uptake of surgical services as deemed fit by
managing physician, when people are adequately informed.

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Description/Definition of breast cancer
• Screening recommendations and simple definitions of screening
modalities
• Catalogue of common symptoms and signs of breast cancer
• Navigation guide following breast cancer screening highlighting all
possible scenarios
• Various treatment modalities available for breast cancer treatment.
• Palliative care- importance and role in breast cancer.
Mobilization, sensitization, creating awareness
• This will be through the provision of an annual work plan targeted
at reaching all afore mentioned groups/population, private health
facilities and NGOs involved in cancer control who have been quality
assured operating within the city and environs of Enugu with a view
to building strong partnerships.
• Media representation to include electronic media and print using
jingles, fliers and granting interviews, targeting individuals and co-
operations that already possess media time.
• Organize outreaches in collaboration with established NGOs and
CSO with similar interest.
• Ensure concise documentation from the planning phase to
implementation to track impact
• All patients with positive screening results to pass through the
navigation unit and breast cancer support group.
OUTLINED PATHWAY
Following SBE, women should visit their local health center/primary health
center or peripheral hospital for CBE. People with suspicious lesions are

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referred to either the clinic at the UNTH outpost (Independence Layout) or
to UNTH Ituku Ozalla. A simple pathway is presented below;
BREAST CANCER
CLINIC- UNTHREFFERRALS FROM MOP,
GYNAE CLINIC,
PERIPHERAL HOSPITALS
SURVIVORSHIP
PALLIATIVE CARE
MULTIDISCIPLENARY ONCOLOGY
MEETING/ TUMOUR BOARD
SUPPORT GROUP/
PSYCHO-ONCOLOGY
PATIENT
NAVIGATION UNIT
PATHOLOGY
MAMMOGRAM/
SONOMAMMO
SEND FOR
RADIOLOGY FOR MAMMO/
SONOMAMMOGRAM
SELF REFERALS,
REFERRALS FROM
PERIPHERAL CLINICS
ONCOLOGY
COMPLEX
NGOs WITH SIMILAR
INTERESTS

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INCREASED RISK
SCREENING RECOMMENDATIONS
16yr- <40yr:
Clinical breast exam every 1- 3yrs Breast
awareness
>40yrs -<50yrs:
Annual Clinical breast exam
Mammogram every 2 years
Breast awareness
>50yrs- 69yrs:
>70 – 74 yrs:
Annual Clinical breast exam Annual
Mammogram Breast awareness
Annual mammogram
>75 yrs:
Annual mammogram until life
expectancy is < 5yrs
NormalRisk
Prior history of breast cancer
Clinical encounter every
6-12 months
Annual mammogram
Pedigree suggestive of known
cancer or genetic predisposition
Prior thoracic radiotherapy for
patients younger than 30yrs

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SECTION THREE
DIAGNOSIS
Broad Objectives
To strengthen and enhance the planning management and operational
capacity of breast cancer diagnosis and imaging modalities at UNTH, for
the provision of efficient and quality service.
The central purpose of this is to provide a road map for strengthening and
improving the provision and delivery of diagnostic services to our patients.
Possible Presentations
• Palpable mass
• Pain +/- mass
• Nipple discharge
• Skin induration/thickening
• Breast asymmetry
Protocol
• History- taking with the breast imaging questionnaire
• Clinical breast examination.

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1.1 WOMEN 40 YEARS AND ABOVE
** The tumour board may consider
referring for breast MRI for complex
masses or equivocal histopathology/
imaging findings
Mastalgia
Mass detected on
SBE/CBE
Mammography +
Sonomammogrpahy
MULTIDISCIPLINARY
ONCOLOGY
MEETING/TUMOUR
BOARD**
Negative
(BIRADS 1)
Simple cyst/
Complex cyst
(BIRADS 2-6)
Macrocalcifica-
tions
Solid/Complex
mass
(BIRADS 2-6) **
Microcalcifica-
tions
Annual Routine
Screening
(CBE,
Mammography)
Ultra-
sound-guided
aspiration
Refer to SOP
FNAC/Needle
biopsy
Stereotactic
biopsy
No Residual
Mass
Residual solid
component
(BIRADS 2-6)
Histopathology
Benign Malignant
Refer to SOP PATIENT
NAVIGATION
UNIT

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Mastalgia
Mass detected
on SBE/CBE
Sonomammo-
grpahy
Negative
(BIRADS 1)
Benign
Refer to SOP
Malignant
PATIENT
NAVIGATION
UNIT
FNAC/Needle
biopsy
Histopathology
Simple cyst/
Complex cyst
(BIRADS 2-6)
Solid/
Complex mass
(BIRADS 2-6) **
Macrocalcifications
Refer to SOP
MULTIDISCIPLINARY
ONCOLOGY
MEETING/TUMOUR
BOARD **
1.2 WOMEN BELOW 40 YEARS
** The tumour board may consider
referring for breast MRI for complex
masses or equivocal histopathology/
imaging findings
Ultra-
sound-guided
aspiration
Annual Routine
Screening
(CBE,
Mammography)
No Residual
Mass
Residual solid
component
(BIRADS 2-6)

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2. UNILATERAL NIPPLE DISCHARGE
Nipple discharge
Sonomammography
discharge
Dilated duct only
Ductulography
Refer to SOP
Negative
(No abnormality
seen)
Dilated duct +
Intraductal mass
seen
Refer to SOP for
excision biopsy

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3. SCREENING
For women with known high risk for breast cancer:
a. Initiate monthly BSE and biennial CBE as soon as the breast buds
appear.
b. Annual sonomammogram from age 20 years.
c. Biennial MRI till the age of 30 and annual MRI till age 39.
d. Annual mammogram from age 40.
e. Any positive finding will follow the outlined pathways already
elaborated
• Following breast screening or after presentation, diagnosis of breast
cancer should be made by triple assessment (clinical assessment,
mammography and/or ultrasound imaging, and core biopsy and/or
fine needle aspiration cytology). It is best practice to carry out these
assessments at the same visit.
• FNAC to be done routinely and turnaround time to be less than
48hours
• Follow up biopsy for immunohistochemistry is encouraged
• Formalin produced by Pathology to be available for collection at
oncology clinic, theatre and pathology department.
TABLE 1. DIAGNOSTIC WORKUP
Assessment of general
health status
History
Menopausal status
Physical examination
Full blood count
Retroviral status
Liver Function tests, SEUCR for all patients.
ECG and 2D Echo for patients planned for
anthracycline, taxanes and trastuzumab.

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Assessment of primary
tumour
Physical examination
Mammography
Breast ultrasound
Core biopsy with pathology determination
of histology, grade, ER, PgR, HER-2
Assessment of regional
lymph nodes
Physical examination
Ultrasound
Ultrasound-guided biopsy if suspicious
Assessment of disease Physical examination
Chest X-Ray-AP/Lateral
Abdominal Ultrasound
Other tests are not routinely recommended,
unless locally advanced/metastatic and
symptoms are suggestive. These include;
Symptom directed Xrays of the individual’s
particular bones
Bone scan
CT Scan Abdomen
CT Scan Thorax
CT Scan Brain
ER, oestrogen receptor; PgR, progesterone receptor; HER2, human
epidermal growth factor 2 receptor.

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TISSUE REPORTING
Using the modified version of the British minimum reporting data set. This
data set includes:
• Histologic disease
• Tumour grading
• Resection margin status
• Number of lymph nodes identified
• Number of lymph nodes involved
• Lymphatic and vascular invasion
• ER, PR and Her2 expression
• ER Quick score system to be used. Negative for scores 3 and lower
and positive for score >3 and above.
• Indicate right or left breast
• Specimen type
• Specimen weight or dimension
• LCIS
• Pagets

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SECTION FOUR
UNTH PATIENT NAVIGATION
General Objectives
Remove barriers in the access to care and improve timely access to care.
Specific Objectives
• To provide individualized support.
• To empower patients.
• To coordinate care.
• To reduce loss to follow-up.
• To serve as an entry point into the health care system for cancer
patients.
• To educate patients.
UNTH BREAST CANCER SUPPORT
GROUP
General Objectives
Improve the quality of life of breast cancer patients and assist in their
financial needs.
Specific Objectives
To provide a setting in which patients with cancer can talk about living with
their disease with others who may be having similar experiences.
• To provide access to the most current information regarding
available treatments, information and education on how to cope with
treatment.

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• To promote awareness regarding cancer prevention, screening,
treatment, counseling, and experience sharing.
• To promote advocacy by encouraging cancer survivors, their family
members, health professionals, social workers, interested individuals
and volunteers to become advocates.

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SECTION FIVE
TREATMENT OF BREAST CANCER
General Statement
The need to develop a protocol for breast cancer treatment is very obvious.
Surveys have shown that adherence to treatment guidelines has been
associated with significant improvement in survival (Griggs et al 2007,
Hassettetal 2008). The treatment guideline is aimed at improving the
standard of care of breast cancer patients particularly in UNTH. It offers
best practice advice on the treatment of breast cancer considering the
world standard of practice and our own peculiar locally prevailing factors.
We had several multidisciplinary meetings to deliberate on the best
treatment practice suited to our practice here in UNTH. These guidelines
are not final but serve as a guide to offer standard best practices
through evidenced based medicine to our patients. With the rapid
development of scientific knowledge, new evidence may emerge between
the time information is developed and when it is published or read
therefore, broad based consultations are encouraged particularly in respect
of dosage modifications, side effects, contraindications, interactions and
co-medications.
It is important to note that individualized treatment plans are highly
recommended and the multidisciplinary spirit in the management of breast
cancer be encouraged
NOTES ON THE SCOPE OF THE GUIDANCE
These guidelines are developed in accordance with a scope that defines
what the guideline will and will not cover.

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Groups covered
Women with newly diagnosed invasive adenocarcinoma of the breast with
clinical stages I, II, III and IV
Men with newly diagnosed invasive adenocarcinoma of the breast of clinical
stages I, II, III and IV
Women with newly diagnosed DCIS/LCIS Women with Paget’s disease of
the breast.
Groups not covered
Women and men with rare breast tumours (for example, angiosarcoma,
lymphoma).
Women and men with benign breast tumours (for example, fibroadenoma,
phyllodes tumour).
STAGING SUMMARY
Primary Tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis In situ cancer or isolated Paget’s disease of the nipple without tumour
(DCIS) Ductal Carcinoma in situ
(LCIS) Lobular carcinoma in situ
Note: Paget’s disease associated with a tumour is classified according to
the size of the tumour.
T1 Tumour 2 cm or less in greatest dimension
T1mic = micro metastases 0.1 cm or less
T1a >0.1 - 0.5 cm

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T1b >0.5 - 1.0 cm
T1c >1.0 – 2.0 cm
T2 Tumour more 2 cm but not more than 5 cm in greatest dimension
T3 Tumour more than 5 cm in greatest dimension
T4 Tumour of any size with direct extension to chest wall or skin
T4a = extension to the chest wall
T4b = oedema, ulceration of the skin or satellite skin nodules
T4c = Both (T4a + T4b)
T4d = Inflammatory carcinoma
N Regional Lymph Node
NX Regional lymph nodes cannot be assessed (e.g. previously removed)
N0 No regional lymph node metastases
N1 Metastases to movable ipsilateral level I, II axillary lymph node(s)
N2 Metastases in ipsilateral level I, II axillary lymph nodes that are clinically
fixed or matted; or in clinically detected ipsilateral internal mammary nodes
in the absence of clinically evident axillary lymph node metastases
N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one
another (matted) or to other structures
N2b Metastases only in clinically detected ipsilateral internal mammary
nodes and in the absence of clinically evident level I, II axillary lymph node
metastases
N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s)
with or without level I, II axillary lymph node involvement; or in clinically
detected ipsilateral internal mammary lymph node(s) with clinically evident
level I, II axillary lymph node metastases; or metastases in ipsilateral

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supraclavicular lymph node(s) with or without axillary or internal mammary
lymph node involvement
N3a Metastases in ipsilateral infraclavicular lymph node(s)
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary
lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)
M Distant Metastases
M0 No clinical or radiographic evidence of distant metastases
M1 Distant metastases present
TABLE 2: GROUP STAGING
Stage 0 Tis, N0, M0
Stage I T1, N0, M0
Stage IIA
T0, N1, M0
T1, N1, M0
T2, N0, M0
Stage IIB
T2, N1, M0
T3, N0, M0
Stage IIIA
T0-2, N2, M0
T3, N1-2, M0
Stage IIIB T4, N0-2, M0
Stage IIIC T0-4, N3, M0
Stage IV T0-4, N0-3, M1

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Definition of risk categories for patients with operable
breast cancer
Low risk Node-negative and all of the following features
pT < 2 cm
Grade 1
Absence of extensive peritumoural vascular
invasion
ER and /or PgR expressed
HER2/neu gene neither overexpressed nor
amplified
Age > 35 years
Intermediate Node-negative and at least one of the following
risk features
pT > 2 cm
Grade 2-3
Presence of extensive peritumoural vascular
invasion
ER and /or PgR absent
HER2/neu gene expression or amplified
Age < 35 years
High risk Node-positive (1-3 involved nodes) and
ER and /or PgR expressed
HER2/neu gene neither overexpressed nor
amplified
Node-positive (1-3 involved nodes) and
ER and /or PgR absent
HER2/neu gene overexpressed or amplified
Node-positive (1-4 involved nodes)

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TABLE 3:
Surrogate definitions of intrinsic subtypes of breast cancer according to
the 2015 St Gallen Consensus Conference and also recommended by the
ESMO Clinical Practice Guidelines
Intrinsic
subtype
Clinicopathologic
surrogate definition
Notes
Luminal A ‘Luminal A-like’
ER-positive
HER2-negative
Ki67 low*
PgR high**
*Ki-67 scores should be
interpreted in the light of
local laboratory values: as
an example, if a laboratory
has a median Ki-67 score
in receptor-positive low-
risk molecular disease of
signature (if available) 20%,
values of 30% or above could
be considered clearly high;
those of 10% or less clearly
low,
**Suggested cut-off value
is 20%; quality assurance
programmes are essential for
laboratories reporting these
results.

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Luminal B ‘Luminal B-like
(HER2-negative)’
ER-positive
HER2-negative and
either Ki67 high or
PgR low
Luminal B
Ki67 high or
high-risk molecular
signature
(if available)
‘Luminal B-like
(HER2- positive)’
ER-positive
any Ki67
any PgR
HER2-positive
overexpression
‘HER2-positive
(non-luminal)’
‘Basal-like’
‘Triple-negative
(ductal)’
HER2-positive
ER and PgR absent
ER and PgR absent
HER2-negative
There is
῀ 80% overlap
between ‘triple-negative’
negative and intrinsic ‘basal-
like’ subtype but ‘triple-
negative’ also includes some
special histological types such
as (typical) medullary and
adenoid cystic carcinoma with
low risks of distant recurrence.
ER, oestrogen receptor;
HER2, human epidermal
growth factor 2 receptor;

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Early Breast Cancer
Breast cancer that has not spread beyond the breast or the axillary lymph
nodes. This includes ductal carcinoma in situ and stage I, stage IIA, and
stage IIB breast cancers
1st visit – history, physical examination with pictorial representation and
special investigations must enable you to summarize, preparing for
definitive management.
For all premenopausal women fertility counseling should be done.
A pathology report is mandatory and should report findings from a core
biopsy rather than an FNA as it more accurately reflects grade, ER/PR status
and HER2 score and reports Lympho-Vascular invasion
Minimal investigations- FBC, SEUCR, LFT, RVS, Alkaline phosphatase,
Serum calcium 2D-ECHO for AC regimen and Taxols CXR- PA/Lateral,
Abdominopelvic USS Bilateral mammogram, Breast Ultrasound
TREATMENT
Stage 0: DCIS, LCIS:
Breast Conserving Surgery(lumpectomy) and whole breast radiotherapy
Total mastectomy without radiotherapy
Systemic treatment
Discuss options and potential side effects with patient
Fill and ensure consent form is duly signed by patient, doctor and witness
prior to commencing systemic treatment
• Endocrine therapy: Consider endocrine therapy for 5 years-
Tamoxifen for premenopausal women and Tamoxifen or Aromatase
Inhibitor for postmenopausal women

36. 36
Surveillance/Follow up
- See general principles
- If breast conservation therapy, mammogram of treated
breast at 6-12 months, then annually
- Annual gynecologic exam, if receiving tamoxifen
- Assess bone health
- Encourage age appropriate cancer and general health guidelines
Stages I, IIA, IIB.
Breast Conserving Surgery (BCS).If it meets the criteria for BCS.
Indications include:
Unifocal
Small, <4cm in averaged sized breast
CONTRA-INDICATION
Locally widespread disease;
Multicentricity;
Diffuse (malignant) micro calcifications;
1st or 2nd trimester pregnancy
Patients with mutations on BR-CA1 and 2 genes;
Already irradiated thoracic wall
Non-availability of radiotherapy
Connective tissue disease e.g scleroderma, SLE
• If BCS is contemplated, the radiation oncologist must be involved
from the onset to book for radiotherapy before the surgery. Option
of BCS to be discussed with women who meet the criteria.
• However, because availability of radiotherapy is uncertain managing
consultant may consider offering mastectomy to the patients.
• Tumour bed should be indicated as much as possible (draw the
position).

37. 37
• Surgeons to liaise with pathologist to determine resection margins/
frozen section
• Axillary dissection may be considered in cases of node-positive
breast cancer.
• Plastic surgeons should be informed for breast reconstruction
• Radiotherapy (RT): whole breast radiotherapy following BCS or chest
wall radiotherapy after mastectomy. Treatment fields are determined
by axillary nodal status.
• Although clinically apparent lymph node relapses (especially axillary
and internal mammary) are rare, nodal irradiation remains indicated
for patients with involved lymph nodes.
• Shorter fractionation schemes are recommended.
• RT should follow chemotherapy if adjuvant chemotherapy is
indicated and can be safely combined with trastuzumab
• Adjuvant chemotherapy commences as soon as the wound has
healed, within 2-6weeks following surgery but not later than 12weeks.
SYSTEMIC THERAPY
Discuss options and potential side effects with patient/care giver
Fill and ensure consent form is duly signed by patient, doctor and witness
prior to commencing systemic treatment.
During chemotherapy, attending doctor MUST state the duration of
infusion.
• Preoperative chemotherapy should be considered in patients with
any of the following:
• T3 disease
• Node-positive disease

38. 38
• ER-negative disease
• HER2-positive disease
• Downsizing tumours for surgery
•
Treatment choice should be individualized and based on the predicted
sensitivity to treatment types, the benefit from their use and an individual’s
risk of relapse and should incorporate the treatment sequelae, patients’
biological age, general health status, co-morbidities and preferences.
4 cycles of doxorubicin and cyclophosphamide are considered to be
equivalent to 6 cycles of CMF.
PREOPERATIVE
CHEMOTHERAPY
CONFIRMED
PROGRESSIVE
DISEASE
MASTECTOMY
PARTIAL
RESPONSE
MASTECTOMY
PARTIAL
RESPONSE,
BCS POSSIBLE
BCS
COMPLETE
RESPONSE
BCS

39. 39
The addition of taxanes improves the efficacy of chemotherapy
independently of age, nodal status, tumour size or grade, steroid receptor
expression or tamoxifen use, but at the cost of increased toxicities.
Non-anthracycline, taxane-based regimens, such as 4 cycles of docetaxel
and cyclophosphamide, may be an alternative for selected patients, for
example, those at risk of cardiac complications.
The use of dose-dense schedules (with granulocyte colony-stimulating
factor support) should be considered, particularly in highly proliferative
tumours.
Chemotherapy is recommended in the vast majority of triple-negative, HER2-
positive breast cancers and in high-risk luminal HER2-negative tumours.
Most luminal A tumours, except those with the highest risk of relapse
(extensive nodal involvement), require no chemotherapy.
• For luminal HER2 negative cancers, the indications for chemotherapy
depend on the individual risk of relapse presumed responsiveness to
ET and patient preferences. In general, chemotherapy should not be
used concomitantly with ET.
• Luminal B HER2 positive tumours are treated with chemotherapy, ET
and trastuzumab. In cases of contraindications for chemotherapy or
patient refusal, in selected cases it may be acceptable to offer the
combination of targeted agents (ET and trastuzumab).
• HER2 positive (non-luminal) cancers should be treated with
chemotherapy plus trastuzumab
Dose adjustments are advised in patients with renal or liver pathologies.

40. 40
Chemotherapy Regimens
HER-2 negative disease
Preferred regimens
• AC → T AC: Doxorubicin 60 mg/m2
IV plus cyclophosphamide 600
mg/m2
IV on day 1 every 3 wk for four cycles followed by Paclitaxel
80 mg/m2
IV weekly X12 or Docetaxel 75mg/ m2
X 4 doses with
prophylactic filgastrim support.
• Or dose dense AC (every 2 weeks) followed by weekly paclitaxel x 12,
or dose dense paclitaxel every 2 weeks- with filgastrim support
• Fluorouracil, doxorubicin, and cyclophosphamide (FAC) followed by
weekly paclitaxel
Other regimens
• Docetaxel and cyclophosphamide (TC) ( particularly for node
negative or low risk node positive disease) : Docetaxel 75 mg/m2
IV
on day 1 plus cyclophosphamide 600 mg/m2
IV on day 1 every 3 wk
for four cycles
• Dose-dense doxorubicin and cyclophospamide (AC) followed by
docetaxel every 3 weeks:
• TAC: Docetaxel 75 mg/m 2
IV on day 1 plus doxorubicin 50 mg
/m2
IV on day 1 plus cyclophosphamide 500 mg/m2
IV on day 1 every
3 wk for six cycles
HER-2 positive disease
General considerations
Trastuzumab should be used in patients with tumours that over-express
HER2/neu (3+ when more than 10% of the cells, harbour a complete
membrane staining) and may be considered if a HER2 test is equivocal,

41. 41
according to the new guideline recommendation by ASCO. Recommended
duration of treatment is 12 months.
Before commencing treatment with trastuzumab, cardiac function should
be assessed. Do not offer trastuzumab treatment to women with any of the
following:
- left ventricular ejection fraction (LVEF) of 55% or less
- history of documented congestive heart failure
- high-risk uncontrolled arrhythmias
- angina pectoris requiring medication
- clinically significant valvular disease
- evidence of transmural infarction on electrocardiograph (ECG)
- poorly controlled hypertension.
Cardiac function should be monitored every 3 months during
trastuzumab treatment. If the LVEF drops by 10 percentage (ejection)
points or more from baseline and to below 50% then trastuzumab
treatment should be suspended and can only be restarted after
further cardiac assessment and a fully informed discussion of the
risks and benefits with the patient. Trastuzumab should not be given
concurrently with anthracyclines. When using the AC-T regimen, it
should be commenced with the taxane and continued after the end of
the chemotherapy for one year.
First-line cytotoxic therapy should always be given in combination with
trastuzumab. Trastuzumab regimens are 4 mg/kg IV on day 1 followed by
2 mg/kg IV weekly or 8 mg/kg IV on day 1 followed by 6 mg/kg every 3 wk.
In patients who have progression after initial therapy, anti-HER2 therapy
should be continued by either continuing trastuzumab and changing
cytotoxic therapy or switching to lapatinib plus capecitabine.

42. 42
Preferred regimens
• Doxorubicin and cyclophospamide (AC) followed by paclitaxel plus
trastuzumab: Doxorubicin 60 mg/m2
IV plus cyclophosphamide
600 mg/m2
IV on day 1 every 3 wk, followed by paclitaxel 80 mg/m2
IV
weekly for 12 cycles or 175 mg/m 2 IV every 3 wk for four cycles given
concurrently with trastuzumab 4 mg/kg for the first dose and then
2 mg/m2
weekly with each paclitaxel dose; followed by trastuzumab
6 mg/kg every 3 wk for 14 doses, for a 1-y total duration of
trastuzumab therapy
• AC → docetaxel plus trastuzumab
• Docetaxel, carboplatin, trastuzumab (TCH): Docetaxel 75 mg/m2
plus carboplatin AUC 6 IV on day 1 every 3 wk for six cycles and
transtuzumab
Other regimens
• Weekly paclitaxel plus trastuzumab (for low-risk disease, such as
Stage I)
Endocrine therapy
Only offered to patients with ER+/PR+ tumours (i.e. tumours with > 1%
expression ER on invasive cancer cells)
For early stage premenopausal- give chemo first due to inadequate staging
of our patients and afterwards commence on endocrine therapy.
Options for endocrine therapy in breast cancer patients include the following:
• Tamoxifen
• Aromatase inhibitors (AIs)
• Luteinizing hormone–releasing hormone (LHRH) analogues
• Oophorectomy may produce additional benefit

43. 43
Regimens for premenopausal patients are as follows:
• Tamoxifen 20 mg PO daily for 5 yrs
• Tamoxifen 20 mg PO daily for 2-5 yrs, followed by an AI for a total
of up to 5 -10yrs; this regimen is typically used for patients who are
pre- or peri-menopausal at diagnosis and become postmenopausal
during therapy
• Ovarian suppression with LHRH analogues, may be added to
tamoxifen or an AI.
• Ovarian suppressive treatment is generally administered for 2-5 years
• A combination of ovarian ablation and tamoxifen in ER-positive
patients can be used as an alternative to cyclophosphamide/
methotreaxate/fluorouracil (CMF)-type chemotherapy.
Post menopausal – definition; as recommended by NCCN guideline
Permanent cessation of menstruation as evidenced by:
Prior bilateral oophorectomy
Age 60yrs and above,
If less than 60yrs has been amenorrheic for 12 or more months in the
absence of chemotherapy and endocrine manipulation
Plasma estradiol in postmenopausal ranges (0-40 pg/mL)
Regimens for postmenopausal patients
Regimens are as follows:
AIs for 5y, either alone or sequentially after 2-5 y of tamoxifen: anastrozole
1 mg PO daily or letrozole 2.5 mg PO daily or exemestane 25 mg PO daily
Tamoxifen 20 mg PO daily for 5 yrs

44. 44
TRIPPLE NEGATIVE DISEASE
Chemotherapy is the backbone. Addition of Platinum compounds has
shown an increase in pCR.
• AC-T; T AC: Doxorubicin 60 mg/m2
IV plus cyclophosphamide
600 mg/m2
IV on day 1 every 3 wk for four cycles followed by
paclitaxel 80 mg/m 2
IV weekly X12
NOTE: IF NO CLINICAL RESPONSE AFTER 2-3 CYCLES OF AC, SWITCH
TO PLATINUM
• Carboplatin AUC 6 IV on day 1 every 3 weeks plus Paclitaxeal 80
mg/m 2
IV weekly X12
Other Combinations
• Epirubicin, cisplatin and fluorouracil (ECF) × 4 followed by weekly
paclitaxel X12
• Epirubicin, cyclophosphamide (EC) × 4 followed by docetaxel +/−
carboplatin
If no pCR, adjuvant chemotherapy is advised.

45. 45
LOCALLY ADVANCED BREAST
CANCER (LABC)
All patients to be discussed at multidisciplinary meeting
All patients to be referred to palliative care
We define LABC as any tumor that is greater than 5 cm with fixed axillary lymph
nodes or ipsilateral supraclavicular, infraclavicular, or internal mammary nodal
involvement or tumours that involve the skin or chest wall. Thus, all of stage III
disease is considered locally advanced, as is a subset of stage IIB (T3N0)
• Therapeutic options for locally advanced disease MUST include
preoperative (neoadjuvant) chemotherapy (as above) to optimize
surgical options and determine systemic efficacy.
• Preoperative systemic chemotherapy is indicated for all patients
with inflammatory breast carcinoma, ipsilateral supraclavicular
adenopathy, bulky axillary adenopathy, extension to the skin or chest
wall, or a large (>5 cm) primary tumor
• Discuss options for systemic treatment and potential side effects with
patient
• Fill and ensure consent form is duly signed by patient, doctor and
witness prior to commencing systemic treatment
• Anthracycline based chemotherapy is regarded as standard of care
and should be sequenced with the taxanes (as in the previous section)
• For triple negative tumours, the addition of the platinum compounds
has been shown to improve pCR.
• Patients with responding tumors should receive neoadjuvant
treatment for up to 8 cycles,
• Patients who do not respond after 4 cycles of optimally dosed
anthracyclines generally should receive local treatment.

46. 46
• Chemotherapy generally is completed before surgery, and there are
no data yet to support additional chemotherapy after surgery
• Endocrine therapy should be given after surgery for hormone-
responsive tumors for 10 years.
• For Her2neu positive tumours, trastuzumab therapy should continue
post surgery at 3-week intervals for 1 year or until disease recurrence
(whichever is the shorter period),
• Mastectomy with axillary dissection should be offered to all patients
with inflammatory breast cancer after neoadjuvant chemotherapy
and breast reconstruction should be delayed.
• Radiotherapy: Post mastectomy radiotherapy is to the chest wall,
axilla, supraclavicular and internal mammary chain.
• Biphosphonate therapy should commence immediately and should
last for 1year.
SURVEILLANCE
- See general guidelines
- If breast conservation therapy, mammogram of treated breast at
6-12 months, then annually.
- Annual gynecologic exam, if receiving tamoxifen
- Assess bone health
- Encourage age appropriate cancer and general health guidelines
- Educate, screen and refer for lymphedema management as needed
STAGE IV DISEASE
All patients to be discussed at multidisciplinary meeting
All patients to be referred to palliative care
Recurrent disease: Re-biopsy all new lumps
For local recurrence, treatment will depend on was performed previously.

47. 47
For example, if BCS was performed initially, then total mastectomy will be
performed now. If patient had radiotherapy previously, then radiotherapy
will not be offered.
Metastatic Breast Cancer
THERAPEUTIC GOALS —The primary goals of systemic treatment for
metastatic breast cancer are prolongation of survival, alleviation of
symptoms, and maintenance or improvement in quality of life, despite the
toxicity associated with treatment.
Systemic Therapy:
• Discuss options and potential side effects with patient
• Fill and ensure consent form is duly signed by patient, doctor and
witness prior to commencing systemic treatment.
• In patients with ER and/or PR expression who have none or minimal
disease symptoms and bone-only disease or a low disease burden,
endocrine therapy is always preferred to other therapeutic options
because of its favorable toxicity profile relative to other alternatives.
Continue ET until progressive disease or unacceptable toxicity
then consider alternate endocrine therapy
• Chemotherapy is used in patients with resistance to endocrine therapy or
ER/PR-negative disease and a moderate or high disease burden
• Single-agent sequential cytotoxic therapy is preferred; combination
cytotoxic therapy is associated with a higher response rate, but it is
also more toxic
• Continue chemotherapy until disease progression or until unacceptable
toxicity reached and revert to best supportive care/palliative care

48. 48
Endocrine therapy in premenopausal women
• Recommended treatment is Tamoxifen.
• Gonadotropin-releasing hormone (GRH) analogues may be used to
suppress ovarian estrogen production plus endocrine therapy with
tamoxifen or an AI.
Postmenopausal breast cancer patients
• AIs have been shown to have longer disease free survival than
tamoxifen for adjuvant therapy and metastatic disease
• Patients who relapse or have progressive disease on tamoxifen may
be switched to an AI
• Patients who relapse or progress while receiving a nonsteroidal
AI (eg, anastrozole or letrozole) or a steroidal AI (eg, exemestane)
should be changed to or a selective ER-down regulator (eg, fulvestrant)
• Fulvestrant regimen is 500 mg IM on days 1 and 14, then on day 1
every 4 wk
• Optionally, consider the androgenic agent fluoxymesterone 10 mg
PO BID or the progestational agent megestrol acetate 40 mg PO
QID or estradiol 2 mg PO BID
Chemotherapy for Recurrent or Metastatic Disease
Chemotherapy should be based on the concept of following a treatment
continuum in responders (1st, 2nd, 3rd line therapies) ensuring non-
overlapping toxicities.
• Systemic chemotherapy should be reserved for patients with hormone-
insensitive disease or for patients with symptomatic hormone-sensitive
diseasewhohavefailedallhormonetherapyoptionsorwhoaremoderately
to severely symptomatic and in urgent need of symptom palliation

49. 49
• The options for cytotoxic-containing chemotherapy include single-
agent therapy and combination cytotoxic therapy
Preferred single-agent regimens:
• Doxorubicin 60-75 mg/m2
on day 1 every 3 wk or 20 mg/m2
IV weekly
• Epirubicin 60-90 mg/m2
IV on day 1 every 3 wk
• Paclitaxel 175 mg/m2
IV on day 1 every 3 wk or 80 mg/m 2
IV weekly
• Docetaxel 60-100 mg/m2
IV on day 1 every 3 wk or 40 mg/m2
IV
weekly for 6 wk followed by a 2-wk rest and then repeated
- Capecitabine 1000-1250 mg/m2
PO BID on days 1-14 every 3 wk
- Gemcitabine 800-1200 mg/m2
IV on days 1, 8, and 15 every 4 wk
- Vinorelbine 25 mg/m2
IV weekly
Preferred chemotherapy combinations
Regimens are as follows:
1st Line Chemotherapy Considerations
• CAF: Cyclophosphamide 100 mg/m2
IV on day 1 plus doxorubicin
(Adriamycin) 30 mg/m2
IV on days 1 and 8 plus 5-fluorouracil (5-FU)
500 mg/m2
IV on days 1 and 8 every 4 wk for six cycles
• FAC: 5-FU 500 mg/m2
IV on days 1 and 8 or days 1 and 4 plus
doxorubicin 50 mg/m2
IV on day 1 plus cyclophosphamide 500 mg/
m2
IV on day 1 every 3 wk for six cycles
• FEC: 5-FU 500 mg/m2
IV plus epirubicin 100 mg/m2
2 IV plus
cyclophosphamide 500 mg/m2
IV on day 1 every 3 wk for three cycles
• AC: Doxorubicin 60 mg/m 2
IV plus cyclophosphamide 600 mg/m 2
IV
on day 1 every 3 wk for four cycles
• EC: Epirubicin 100 mg/m2
IV on day 1 plus cyclophosphamide 830
mg/m2
IV on day 1 every 3 wk for eight cycles
• AT: Doxorubicin 50 mg/m2
IV plus paclitaxel 125-200 mg/m2
every 3 wk
• AT: Doxorubicin 50 mg/m2
IV plus docetaxel 75 mg/m2
IV every 3 wk

50. 50
• CMF: Cyclophosphamide 100 mg/m2
IV PO on days 1-14 plus
methotrexate 40 mg/m2
IV on days 1 and 8 plus 5-FU 600 mg/m2
IV
on days 1 and 8 every 4 wk
2nd Line Chemotherapy Considerations
• Docetaxel/capecitabine: Docetaxel 75 mg/m2
IV on day 1 plus
capecitabine 950 mg/m2
PO BID on days 1-14 every 3 wk
• GT: Paclitaxel or Docetaxeal: Paclitaxel 175 mg/m 2 on day 1 plus
gemcitabine 1250 mg/m 2 IV on days 1 and 8 (following paclitaxel
on day 1) every 3 wk OR Docetaxell 75mg/ m2
on day 1 plus
Gemcitabine 1000mg/ m2
on day 1 and 8 every 3 weeks.
• Gemcitabine/ Carboplatin: Gemcitabine 1000mg/ m2
on day 1 and 8
every 3 weeks and Carboplatin AUC 2 1V on days 1 and 8, every
3 weeks.
3rd Line Chemotherapy Considerations
• Vinoelbine 25 mg/m2
IV weekly
• Eribulin 1.4 mg/m2
IV on days 1 and 8 every 3 wk (not readily available)
HER2/neu+ Metastatic Disease
Preferred first-line single agents with trastuzumab
Regimens are as follows:
• Paclitaxel 175 mg/m2
IV on day 1 every 3 wk
• Paclitaxel 80-90 mg/m2
IV weekly
• Docetaxel 80-100 mg/m2
IV on day 1 every 3 wk
• Docetaxel 35 mg/m2
IV weekly
• Vinorelbine 25 mg/m2
IV weekly
• Capecitabine 1000-1250 mg/m2
PO BID on days 1-14 every 3 wk

51. 51
Preferred combination chemotherapy with trastuzumab
Regimens are as follows:
• TCH: Carboplatin AUC 6 IV on day 1 plus paclitaxel 175 mg/m2
IV on
day 1 every 3 wk
• Weekly TCH: Paclitaxel 80 mg/m2
IV on days 1, 8, and 15 plus
carboplatin AUC 2 IV on days 1,8, and 15 every 4 wks
Bone Disease
Recommended therapy include
Palliative Radiotherapy
Zoledronic acid 4 mg IV over 15 min. (it is readily available)
Others include: Denosumab or Pamidronate
BREAST CANCER MANAGEMENT
IN PREGNANCY
Palpable mass greater than 2 weeks
History and physical
Bilateral mammogram with fetal shielding/ultrasound of breast and nodal
basins Core biopsy
All patients to be discussed at multidisciplinary meeting
• First Trimester: advise for termination and treat as non-pregnant
patient.
• First Trimester:
- No radiotherapy
- no chemotherapy,
- surgery – mastectomy.

52. 52
• Second Trimester:
- No radiotherapy, can take chemotherapy- consider Anthracycline
and/or Taxane therapy, & surgery – mastectomy
• Third trimester:
- No radiotherapy, can take chemotherapy- Anthracycline and/or
Taxane therapy, surgery – mastectomy
- Stop chemotherapy 3 weeks before delivery. Radiotherapy &
Endocrine therapy should be postpartum
MALE BREAST CANCER
Mastectomy with axillary dissection remains the standard surgical treatment.
• Locoregional radiotherapy is very often indicated.
• Indications for adjuvant therapies are similar to those in women.
• Tamoxifen is the standard adjuvant treatment, but chemotherapy
is proposed in young men with axillary nodal involvement and/or
negative HR status.
• For metastatic disease, tamoxifen is still the mainstay for HR-positive
disease. For HR-negative disease, doxorubicin-based chemotherapy
regimens are used.
GENERAL FOLLOW UP CARE
The aims of follow-up are:
• To detect early local recurrences or contralateral breast cancer.
• To evaluate and treat therapy-related complications (such as
menopausal symptoms, osteoporosis and second cancers).
• To motivate patients continuing ET.

53. 53
• To provide psychological support and information in order to enable
a return to normal life after breast cancer.
In general patients should be followed up 3 to 4 monthly in the first 2yrs
after treatment. Then 6 monthly from years 3-5 and subsequently once
every year for 10 years.
During such appointments:
Review patients history
Physical examination, both general and specific examination Investigations:
mammography annually
Patient on Tamoxifen – gynaecologic assessment annually
Bone mineral density determination particularly for patients on AI
Laboratory investigations usually based on complaints and findings
Counsel patient on:
Active lifestyle
Healthy diet
Limited alcohol intake
Maintenance of ideal body weight (20-25 BMI).
Patients undergoing ovarian suppression and those taking AIs are at
an increased risk of bone loss and should be advised to have adequate
calcium and vitamin D3 intake. In addition, periodic assessment of their
bone mineral density should be undertaken
Encourage patient(and caregivers) to join the cancer support group
activities including the cancer survivorship meeting at UNTH.

54. 54
MANAGAING SOME
COMPLICATIONS
Lymphoedema
Discuss with people who have or who are at risk of breast-cancer related
lymphoedema that there is no indication that exercise prevents, causes or
worsens lymphoedema.
Discuss with people who have or who are at risk of breast cancer related
lymphoedema that exercise may improve their quality of life.
Advice patients to avoid lifting weights and chemotherapy injuries on the
affected side.
Investigate patients with lymphoedema to exclude medical underlying
factors before starting any lymphoedema management programme.
Refer patients undergoing mastectomy and axillary surgery to the Exercise
Immunology/Palliative care physiotherapy unit for functional exercises
which should commence after surgery and also patients who report a
persistent reduction in shoulder and arm mobility after surgery.
Cancer-related fatigue
Offer all patients with advanced breast cancer for whom cancer related
fatigue is a significant problem an assessment to identify any treatable
causative factors, and offer appropriate management as necessary.
Provide written information about cancer-related fatigue.
Refer to psychologist (to offer psychosocial support) and support group.
Increase in physical activity levels should be encouraged, prescribed and
monitored by the exercise immunology physiotherapists

55. 55
Uncontrolled local disease
All patients presenting with uncontrolled local disease to be seen by the
multidisciplinary team and palliative care team to assess and discuss the
therapeutic options for controlling the disease and relieving symptoms.
A wound care team will see all patients with fungating tumours to plan a
dressing regimen and supervise management with the breast care team.
Bone metastases
Consider offering bisphosphonates to patients newly diagnosed with bone
metastases to prevent skeletal-related events and reduce pain.
Radiotherapy where possible in patients with bone metastases and pain.
Consider orthopaedic review for all patients at risk of a long bone fracture,
to consider prophylactic surgery.
Brain metastases
Offer palliative radiotherapy, chemotherapy and best supportive care
Refer palliative care unit

56. 56
SECTION SIX
PALLIATIVE CARE
KEY RECOMMENDATIONS
• Patients with advanced cancer, whether in patient or outpatient,
should receive dedicated palliative care services, early in the disease
course, concurrent with active treatment.
• Providers may refer caregivers of patients with early or advanced
cancer to palliative care service
SPECIFIC RECOMMENDATIONS
• Patients with advanced cancer should be referred to interdisciplinary
palliative care teams (consultation) that provide inpatient and
outpatient care early in the course of disease, alongside active
treatment of their cancer
• Early palliative care involvement within 8 weeks of diagnosis
• Palliative care across the continuum should complement existing
supportive care programs (eg, social work, pain management,
pastoral care) and may serve to ensure coordination and
communication across these services.
• 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).

57. 57
CRITERIA FOR PALLIATIVE CARE ASSESSMENT AT THE
TIME OF ADMISSION
Primary
• Surprise Question: Would you be surprised if patient died within 12
months or before adulthood?
• Frequent admission: e.g. one admission for same condition within
several months
• Admission prompted by difficult-to-control/distressing physical or
psychological symptoms: Eg. Pain, diarrhoea, vommiting, insomnia,
depression
• Complex care requirements: Eg. ICU/Ventilator
Secondary
• Metastatic or locally-advanced incurable cancer
• Multi-morbidity
• Edmonton Symptom Assessment Scale (ESAS) score of >30
• Multi-organ failure
• Presence of other chronic debilitating conditions: Eg. Hypertension,
diabetes, HIV/AIDS, renal failure
• No history of completing advanced care planning documents
• Family members/carers have emotional, spiritual, or relational
distress
• Family members/carers request for palliative care/hospice services
• Patient’s primary team of doctors request for palliative care

58. 58
SECTION SEVEN
SURVIVORSHIP
Addresses the following:
• Late Effects/Long-Term Psychosocial and Physical Problems
- Anthracycline-Induced Cardiac Toxicity
- Anxiety and Depression
- Cognitive Function
- Fatigue
- Menopause-Related Symptoms
- Pain
- Sexual Function
- Sleep Disorders
• Preventive Health
- Healthy Lifestyles
- Physical Activity
- Nutrition and Weight Management
- Supplement Use

59. 59
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sites/instituteforquality.org/files/chemothera py_consent_form.doc. Accessed March 29, 2017.
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Appendix A
UNTH CONSENT TO CHEMOTHERAPY FORM
Name of patient __________________________________________________
Age Sex
Managing Unit____________________________________________________
Consultant in Charge_______________________________________________
I,_________________________,understand that I have been diagnosed with
_________________________________________________________________
_________________________________________________________________
I understand that the treatment suggested by my doctor,
Dr. ____________________________ , will involve_______________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Name of proposed chemotherapy regimen, dosage and duration
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

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The goal of my treatment is (Curative, Palliative intent)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
I understand that the chemotherapy medications recommended by my
doctor can have short-term and long-term side effects. My doctor talked
to me about the following side effects that I might experience because
of my chemotherapy: (check all that apply; additional space provided for
physician comments)
Nausea/Vomiting
Hair Loss
Low red blood cell count/Anaemia
Risk of Bleeding ______________________________________________
Constipation _________________________________________________
Diarrhea _____________________________________________________
Sores of Mouth and Throat _____________________________________
Skin Effects __________________________________________________
Muscle/Bone Effects __________________________________________
Nerve Effects ________________________________________________
Kidney/Bladder Effects ________________________________________
Sexual Effects ________________________________________________
Heart Effects _________________________________________________
Lung Effects __________________________________________________
Reproductive/Fertility Effects ___________________________________
Other _______________________________________________________

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I understand that complications from chemotherapy could cause my
death.
I understand that I could have side effects from my chemotherapy that
are not listed on this form. Each patient can respond differently to
chemotherapy, and could have side effects that have not been reported
by others.
The reasonable alternatives to this chemotherapy treatment have been
explained to me, including: _________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Patient Signature _________________________________ Date____________
For patients requiring translation or verbal reading of this document, the
person reading/translating should document and sign below:
Reader/Translator Signature________________________ Date____________
Doctor’s Signature________________________________ Date____________

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NOTE TO DOCTOR - CONSENT FORM TO BE
ADMINISTERED BY A RESIDENT OR CONSULTANT
Points to note when discussing with the patient
Is the patient aware of the type and stage of the disease?
What does this mean in terms of the patient’s treatment options?
Are there any results of diagnostic tests the patient should be made aware
of (that would influence his or her treatment decisions)?
What are the names of the drugs the patient will receive as part of his or
her chemotherapy regimen?
How will the treatment be administered?
Who will administer the treatment?
What is the intent of the treatment (e.g. possibly curative, to prolong
survival, to manage symptoms and make the patient comfortable)?
What benefits might a patient expect if treatment is successful?
What risks/side effects are commonly experienced by patients receiving
the proposed drug therapy?
What risks/side effects are less common among patients receiving the
proposed chemotherapy regimen, but are very severe (e.g., paralysis,
death, or permanent disability)?
Does the patient have specific medical, personal or social concerns that
make some risks more or less material than others?
Are there any alternatives to treatment this patient could feasibly pursue?

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Is receiving treatment that is not curative, but is designed to manage
symptoms and promote the patient’s comfort a reasonable alternative?
Does the patient understand that he or she can decide to stop treatment
at any time?
Does the patient have an adequate understanding of the proposed
treatment, including risks, benefits and alternatives?
Does the patient need some of the information repeated? Would
supplemental materials be helpful? Health care providers can assess the
patient’s understanding and repeat or provide supplemental information
where necessary.
Does the patient understand that he or she can ask questions at any time,
even after signing the consent form?
The consent form should document whether the patient received
additional educational materials to take home.

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Notes

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