Early and Locally Advanced Breast Cancer: Diagnosis and Management

Overview

This secondary care Guidelines summary covers diagnosing and managing early and locally advanced breast cancer. It aims to help secondary healthcare professionals offer the right treatments to people, taking into account the person's individual preferences.

This summary covers diagnosis and assessment, surgery, adjuvant therapy, and neoadjuvant therapy. For further detail on topics to discuss with patients, in particular the benefits and risks of treatments, refer to the full NICE guideline.

A table of NHS England interim treatment regimens gives possible alternative treatment options for use during the COVID-19 pandemic to reduce infection risk. This may affect decisions for patients with early and locally advanced breast cancer. See the COVID-19 rapid guideline: delivery of systemic anticancer treatments for more details.

NICE has also produced guidelines on advanced breast cancer, familial breast cancer, and suspected cancer: recognition and referral.

Reflect on your learning and download our Reflection Record.

Preoperative Assessment

• For people having investigations for early and locally advanced invasive breast cancer:
  • perform pretreatment ultrasound evaluation of the axilla, and
  • if abnormal lymph nodes are identified, perform ultrasound-guided needle sampling
• Do not routinely use magnetic resonance imaging (MRI) of the breast in the preoperative assessment of people with biopsy-proven invasive breast cancer or ductal carcinoma in situ (DCIS)
• Offer MRI of the breast as part of preoperative assessment to people with invasive breast cancer:
  • if the extent of disease is not clear from clinical examination, mammography and ultrasound assessment for planning treatment
  • if accurate mammographic assessment is difficult because of breast density
  • to assess the tumour size if breast-conserving surgery is being considered for invasive lobular cancer.

Genetic Testing

• Offer genetic testing for BRCA1 and BRCA2 mutations to women under 50 years with triple-negative breast cancer, including those with no family history of breast or ovarian cancer. (Also see the recommendations on genetic testing in the NICE guideline on familial breast cancer.)

Providing Information and Psychological Support

• Ensure all people with breast cancer have a named clinical nurse specialist, or other specialist key worker with equivalent skills, to support them throughout diagnosis, treatment and follow-up
• Offer all people with breast cancer prompt access to specialist psychological support and, where appropriate, psychiatric services
• Discuss opportunities for people with breast cancer to be involved in research, and encourage entry into clinical trials and other studies
• For guidance on fertility preservation, see the recommendations on people with cancer who wish to preserve fertility in the NICE guideline on fertility problems.

Surgery to the Breast

• Offer further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery where invasive cancer or DCIS is present at the radial margins ('tumour on ink'; 0 mm)
• For women who have had breast-conserving surgery where invasive cancer or DCIS is present within 2 mm of, but not at, the radial margins (>0 mm and <2 mm):
  • discuss the benefits and risks of further surgery (re-excision or mastectomy) to minimise the risk of local recurrence
  • take into account the woman's preferences, comorbidities, tumour characteristics and the potential use of radiotherapy (see also the section on Radiotherapy after Breast-conserving Surgery)
• All breast units should audit their recurrence rates after treatment.

Paget's Disease

• Offer breast-conserving surgery with removal of the nipple–areolar complex as an alternative to mastectomy for people with Paget's disease of the nipple that has been assessed as localised. Offer oncoplastic repair techniques to maximise cosmesis.

Surgery to the Axilla

Invasive Breast Cancer

• Perform surgery using sentinel lymph node biopsy (SLNB) rather than axillary lymph node clearance to stage the axilla for people with invasive breast cancer if they have: 
  • no evidence of lymph node involvement on ultrasound, or
  • a negative ultrasound-guided needle biopsy
• Perform SLNB using the dual technique with isotope and blue dye
• Breast units should audit their axillary recurrence rates.

Ductal Carcinoma In Situ

• Do not routinely perform SLNB for women with a preoperative diagnosis of DCIS who are having breast-conserving surgery, unless they are considered to be at high risk of invasive disease. People at high risk of invasive disease include those with a palpable mass or extensive microcalcifications
• Offer SLNB to all people who are having a mastectomy for DCIS.

Evaluation and Management of a Positive Axillary Lymph Node Identified by a Preoperative Ultrasound-guided Needle Biopsy

• Offer axillary node clearance to people with invasive breast cancer who have a preoperative ultrasound-guided needle biopsy with pathologically proven lymph node metastases.

Evaluation and Management of a Positive Axillary Lymph Node Identified by a Sentinel Lymph Node Biopsy (in People With a Normal Preoperative Ultrasound-guided Needle Biopsy)

• Offer further axillary treatment (axillary node clearance or radiotherapy) after SLNB to people who have 1 or more sentinel lymph node macrometastases
• Discuss the benefits and risks of not having further axillary treatment after primary breast-conserving surgery (within clinical trials where available) with women who:
  • have 1 or 2 sentinel lymph node macrometastases, and
  • have been advised to have whole-breast radiotherapy with systemic therapy (which may be endocrine therapy)
• Do not offer further axillary treatment to people who only have micrometastases in their sentinel lymph nodes after primary surgery for invasive breast cancer
• Do not offer further axillary treatment to people who have isolated tumour cells in their sentinel lymph nodes after primary surgery for invasive breast cancer. Classify this as lymph node-negative breast cancer.

Breast Reconstruction

• Offer breast reconstruction to people after they have had mastectomy for breast cancer
• Be aware that some people may prefer not to have breast reconstruction surgery
• Offer immediate breast reconstruction options to women (immediate reconstruction and delayed reconstruction), whether or not they are available locally
• Offer immediate breast reconstruction to women who have been advised to have a mastectomy, including those who may need radiotherapy, unless they have comorbidities that rule out reconstructive surgery
• Discuss the benefits and risks of immediate breast reconstruction and delayed breast reconstruction with women. Topics to discuss include those in Table 1 in the full guideline, and:
  • the timing of breast reconstruction surgery (at the same time as mastectomy or later)
  • different breast reconstruction surgery options and what they involve
  • how the timing of breast reconstruction surgery affects the options available
  • the uncertainty over long-term outcomes in women having radiotherapy.

For more information on options for women who choose breast reconstruction, see Table 1 in the full guideline.

Diagnostic Assessment and Adjuvant Therapy Planning

Predictive Factors

• Assess the oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth receptor 2 (HER2) status of all invasive breast cancers simultaneously at the time of initial histopathological diagnosis
• Assess the ER status of all invasive breast cancers using standardised and quality-assured immunohistochemical techniques, and report the results quantitatively
• Assess the PR status of all invasive breast cancers using standardised and quality-assured immunohistochemical techniques, and report the results quantitatively
• Assess the HER2 status of all invasive breast cancers using standardised and quality-assured techniques, and report the results quantitatively
• Ensure that the ER, PR, and HER2 statuses are available and recorded at the preoperative and postoperative multidisciplinary team meetings when systemic treatment is discussed.

Adjuvant Therapy Planning

• Consider adjuvant therapy after surgery for people with invasive breast cancer, and ensure that recommendations are recorded at the multidisciplinary team meeting
• Base recommendations about adjuvant therapy on multidisciplinary team assessment of the prognostic and predictive factors, and the possible risks and benefits of the treatment. Make decisions with the person after discussing these factors
• Use the PREDICT tool to estimate prognosis and the absolute benefits of adjuvant therapy for women with invasive breast cancer
• When using the PREDICT tool, be aware that:
  • it is less accurate for:
    • women <30 with ER-positive breast cancer
    • women aged ≥70
    • women with tumours >50 mm
  • it has not been validated in men, and
  • the validation may have under-represented some ethnic groups.
    
    Take into account that the potential limitations in versions of PREDICT after 2.0 may differ from those listed here (also see the PREDICT tool frequently asked questions).

See the NICE guidance on tumour profiling tests for evidence-based recommendations on tumour profiling tests to guide adjuvant chemotherapy decisions.

Endocrine Therapy

• Treat all people with invasive breast cancer with surgery and appropriate systemic therapy, rather than endocrine therapy alone, unless a significant comorbidity means surgery is not suitable for them. 

Adjuvant Endocrine Therapy for Invasive Breast Cancer

• Offer tamoxifen as the initial adjuvant endocrine therapy for men and premenopausal women with ER-positive invasive breast cancer
• Offer an aromatase inhibitor as the initial adjuvant endocrine therapy for postmenopausal women with ER-positive invasive breast cancer who are at medium or high risk of disease recurrence. Offer tamoxifen to women who are at low risk of disease recurrence, or if aromatase inhibitors are not tolerated or are contraindicated.

Ovarian Function Suppression

• Consider ovarian function suppression in addition to endocrine therapy for premenopausal women with ER-positive invasive breast cancer
• Discuss the benefits and risks of ovarian function suppression in addition to endocrine therapy with premenopausal women with ER-positive invasive breast cancer. Explain to women that ovarian function suppression may be most beneficial for those women who are at sufficient risk of disease recurrence to have been offered chemotherapy.

Extended Endocrine (Hormone) Therapy

In June 2023, the use of aromatase inhibitors in the following two recommendations was off label. See NICE's information on prescribing medicines. Please refer to the summary of product characteristics for individual aromatase inhibitors because there are differences in their licensed indications.

• Discuss the benefits and risks of extended endocrine therapy with people who this treatment may be suitable for (see Table 2)
• Offer extended endocrine therapy (past the 5‑year point) with an aromatase inhibitor for postmenopausal women with ER-positive invasive breast cancer who are at medium or high risk of disease recurrence and who have been taking tamoxifen for 2–5 years. Medium or high risk may include people who have lymph node-positive breast cancer, with tumours that are T2 or greater and higher grade
• Consider extended endocrine therapy (past the 5‑year point) with an aromatase inhibitor for postmenopausal women with ER-positive invasive breast cancer who are at low risk of disease recurrence and who have been taking tamoxifen for 2–5 years. Low risk may include people with lymph node-negative breast cancer, with smaller or lower-grade tumours
• Consider extending the duration of tamoxifen therapy >5 years for people with ER-positive invasive breast cancer.

For details of the effects of extended endocrine therapy, see Table 2 in the full guideline.

Endocrine Therapy for Ductal Carcinoma In Situ

• Discuss the benefits and risks (see Table 3) of endocrine therapy after breast-conserving surgery for women with ER-positive DCIS
• Offer endocrine therapy after breast-conserving surgery for women with ER-positive DCIS if radiotherapy is recommended but not received
• Consider endocrine therapy after breast-conserving surgery for women with ER-positive DCIS if radiotherapy is not recommended.

For details of the effects of endocrine therapy after breast-conserving surgery for women with ER-positive DCIS, see Table 3 in the full guideline. 

Adjuvant Chemotherapy for Invasive Breast Cancer

• For people with breast cancer where chemotherapy is indicated, offer a regimen that contains both a taxane and an anthracycline. Refer to the summaries of product characteristics for individual taxanes and anthracyclines to check for differences in licensed indications
• Discuss with people the benefits and risks of adding a taxane to anthracycline-containing regimens. Topics to discuss include those in Table 4 in the full guideline, and:
  • the benefits of reduced cardiac toxicity and reduced nausea
  • the risks of additional side effects, including neuropathy, neutropenia, and hypersensitivity
  • the different side effects and dosing frequencies of different docetaxel and paclitaxel regimens, and the additional clinic visits that may be needed
  • that absolute benefit is proportional to absolute risk of recurrence.
    
    Refer to the summaries of product characteristics for individual taxanes and anthracyclines to check for differences in licensed indications.
     
• Ensure weekly and fortnightly paclitaxel is available locally, as it is better tolerated than 3‑weekly docetaxel, particularly in people with comorbidities.

For details of the benefits and risks of adding a taxane to anthracycline-containing regimens and comparison of different taxane regimens, see Table 4 in the full guideline.

Biological Therapy

• Offer adjuvant trastuzumab for people with T1c and above HER2-positive invasive breast cancer. Give this at 3‑week intervals for 1 year in combination with surgery, chemotherapy, endocrine therapy and radiotherapy, as appropriate
• Consider adjuvant trastuzumab for people with T1a/T1b HER2-positive invasive breast cancer, taking into account any comorbidities, prognostic features, possible toxicity of chemotherapy and the person's preferences
• Use trastuzumab with caution in people with HER2-positive invasive breast cancer who have any of the following:
  • a baseline left ventricular ejection fraction ≤55%
  • a history of, or current, congestive heart failure
  • a history of myocardial infarction
  • angina pectoris needing medication
  • cardiomyopathy
  • cardiac arrhythmias needing medical treatment
  • clinically significant valvular heart disease
  • haemodynamic effective pericardial effusion
  • poorly controlled hypertension.

Bisphosphonate Therapy

Adjuvant Bisphosphonate Therapy

In June 2023, the use of bisphosphonates (zoledronic acid or sodium clodronate) in the following two recommendations was off label. See NICE's information on prescribing medicines.

• Offer bisphosphonates (zoledronic acid or sodium clodronate) as adjuvant therapy to postmenopausal women with node-positive invasive breast cancer
• Consider bisphosphonates (zoledronic acid or sodium clodronate) as adjuvant therapy for postmenopausal women with node-negative invasive breast cancer and a high risk of recurrence
• Discuss the benefits and risks of bisphosphonate treatment with women, particularly the risk of osteonecrosis of the jaw, atypical femoral fractures and osteonecrosis of the external auditory canal. Follow the Medicines and Healthcare products Regulatory Agency/Commission on Human Medicines (MHRA/CHM) advice on bisphosphonates.

Bone Health

• Offer a baseline dual-energy X-ray absorptiometry (DEXA) scan to assess bone mineral density in women with invasive breast cancer who are not receiving bisphosphonates as adjuvant therapy and who:
  • are starting adjuvant aromatase inhibitor treatment, or
  • have treatment-induced menopause, or
  • are starting ovarian ablation/suppression therapy
• Do not offer a DEXA scan to people with invasive breast cancer who are receiving tamoxifen alone
• Offer bisphosphonates to women identified by Algorithms 1 and 2 in Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK expert group (2008; this guidance is not NICE accredited).

Radiotherapy

• Use a radiotherapy technique that minimises the dose to the lung and heart
• Use a deep inspiratory breath-hold radiotherapy technique for people with left-sided breast cancer to reduce the dose to the heart.

Radiotherapy after Breast-conserving Surgery

• Offer whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins
• Consider partial-breast radiotherapy as an alternative to whole-breast radiotherapy for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins and who:
  • have a low absolute risk of local recurrence (defined as women aged ≥50 with tumours that are ≤3 cm, N0, ER-positive, HER2-negative and grade 1 to 2), and
  • have been advised to have adjuvant endocrine therapy for a minimum of 5 years
• If partial-breast radiotherapy (see recommendation above) may be suitable for a woman, discuss the benefits and risks with them and reach a shared decision on its use. Topics to cover include that:
  • local recurrence with partial-breast radiotherapy at 5 years is equivalent to that with whole-breast radiotherapy
  • the risk of local recurrence beyond 5 years is not yet known
  • there is a potential reduction in late adverse effects
• When giving partial-breast radiotherapy, use external beam radiotherapy
• Consider not using radiotherapy for women who:
  • have had breast-conserving surgery for invasive breast cancer with clear margins, and
  • have a very low absolute risk of local recurrence (defined as women aged ≥65 with tumours that are T1N0, ER-positive, HER2-negative and grade 1 to 2) and
  • are willing to take adjuvant endocrine therapy for a minimum of 5 years
• When considering not using radiotherapy for the population in the previous recommendation, discuss the benefits and risks, including those in Table 5 in the full guideline and explain that:
  • without radiotherapy, local recurrence occurs in about 50 women per 1,000 at 5 years, and with radiotherapy, occurs in about 10 women per 1,000 at 5 years
  • overall survival at 10 years is the same with or without radiotherapy
  • there is no increase in serious late effects if radiotherapy is given (for example, congestive cardiac failure, myocardial infarction or secondary cancer).

For details of the benefits and risks of radiotherapy compared with no radiotherapy in the low risk group described in the recommendation above, see Table 5 in the full guideline. 

• Consider adjuvant radiotherapy for women with DCIS following breast-conserving surgery with clear margins. Discuss the possible benefits and risks of radiotherapy (also see the section on surgery to the breast) and make a shared decision about its use.

Radiotherapy after Mastectomy

• Offer adjuvant postmastectomy radiotherapy to people with node-positive (macrometastases) invasive breast cancer or involved resection margins
• Consider adjuvant postmastectomy radiotherapy for people with node-negative T3 or T4 invasive breast cancer
• Do not offer radiotherapy following mastectomy to people with invasive breast cancer who are at low risk of local recurrence (for example, most people who have lymph node-negative breast cancer).

Dose Fractionation for External Beam Radiotherapy

• Offer 26 Gy in 5 fractions over 1 week for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy
• Consider 40 Gy in 15 fractions over 3 weeks for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy when they:
  • have a diagnosis that increases sensitivity to radiotherapy, or
  • have had implant-based reconstruction, or
  • have any other factor that could mean having radiotherapy over 3 weeks is more acceptable (such as, high body mass index [BMI] or fibromyalgia)
• When discussing the benefits and risks of the 2 regimens, follow the recommendations on:
  • enabling patients to actively participate in their care in the NICE guideline on patient experience in adult NHS services, and
  • communicating risks, benefits and consequences in the NICE guideline on shared decision making
• Offer 40 Gy in 15 fractions over 3 weeks for people with invasive breast cancer having regional lymph node irradiation, with or without whole-breast or chest-wall radiotherapy, after breast-conserving treatment or mastectomy

Breast Boost Following Breast-conserving Surgery

• Offer an external beam boost to the tumour bed for women with invasive breast cancer and a high risk of local recurrence, following whole-breast radiotherapy
• Inform women of the risk of side effects associated with an external beam boost to the tumour bed following whole-breast radiotherapy.

Radiotherapy to Nodal Areas

• Do not offer adjuvant radiotherapy to regional lymph nodes to people with invasive breast cancer who have histologically lymph node-negative breast cancer
• Do not offer people with invasive breast cancer adjuvant radiotherapy to the axilla after axillary clearance
• Offer adjuvant radiotherapy to the supraclavicular fossa to people with invasive breast cancer and ≥4 involved axillary lymph nodes
• Offer adjuvant radiotherapy to the supraclavicular fossa to people with invasive breast cancer and 1 to 3 positive lymph nodes if they have other poor prognostic factors (for example, T3 and/or histological grade 3 tumours) and good performance status
• Consider including the internal mammary chain within the nodal radiotherapy target for people with node-positive (macrometastases) invasive breast cancer.

For guidance on intraoperative radiotherapy, see the NICE technology appraisal guidance on the intrabeam radiotherapy system for adjuvant treatment of early breast cancer.

Primary Systemic Therapy

Neoadjuvant Chemotherapy

• Offer neoadjuvant chemotherapy to people with ER-negative invasive breast cancer as an option to reduce tumour size
• Offer neoadjuvant chemotherapy to people with HER2-positive invasive breast cancer in line with the NICE technology appraisal guidance on pertuzumab for the neoadjuvant treatment of HER2-positive breast cancer
• Consider neoadjuvant chemotherapy for people with ER-positive invasive breast cancer as an option to reduce tumour size if chemotherapy is indicated.

Neoadjuvant Chemotherapy Regimens

In June 2023, the use of platinums in the following two recommendations was off label. See NICE's information on prescribing medicines.

• For people with ER/PR/HER2-negative (triple-negative) invasive breast cancer, consider a neoadjuvant chemotherapy regimen that contains both a platinum and an anthracycline
• Discuss the benefits and risks of adding a platinum to an anthracycline-containing neoadjuvant chemotherapy regimen (see Table 6 in the full guideline), and in particular the risk of increased toxicity.

For details of the benefits and risks of adding a platinum to anthracycline-containing neoadjuvant chemotherapy for triple-negative invasive breast cancer, see Table 6 in the full guideline. 

Neoadjuvant Endocrine Therapy

• Consider neoadjuvant endocrine therapy for postmenopausal women with ER-positive invasive breast cancer as an option to reduce tumour size if there is no definite indication for chemotherapy
• Advise premenopausal women that neoadjuvant chemotherapy may be more likely to produce a clinical response than neoadjuvant endocrine therapy, but that some tumours do respond to neoadjuvant endocrine therapy
• Discuss with women the benefits and risks of neoadjuvant endocrine therapy compared with neoadjuvant chemotherapy. Topics to discuss include those in Table 7 in the full guideline.

For details of the benefits and risks of neoadjuvant endocrine therapy compared with neoadjuvant chemotherapy for women with ER-positive/HER-2-negative breast cancer, see Table 7 in the full guideline.

Radiotherapy after Neoadjuvant Chemotherapy

• Offer local treatment with mastectomy (or, in exceptional cases, breast-conserving surgery) followed by radiotherapy to people with locally advanced or inflammatory breast cancer that has been treated with neoadjuvant chemotherapy
• Offer postmastectomy radiotherapy after neoadjuvant chemotherapy if post-treatment histology shows node-positive (macrometastases) breast cancer or involved resection margins
• Offer postmastectomy radiotherapy after neoadjuvant chemotherapy if pretreatment investigations show node-positive (macrometastases) breast cancer
• Consider postmastectomy radiotherapy after neoadjuvant chemotherapy if post-treatment histology shows node-negative T3 breast cancer
• Consider postmastectomy radiotherapy after neoadjuvant chemotherapy if pretreatment investigations show node-negative T3 breast cancer.

Complications of Local Treatment and Menopausal Symptoms

Lymphoedema

• Inform people with breast cancer about lymphoedema and their risk of developing it after treatment with surgery and radiotherapy (see recommendation below). Give them relevant written information before treatment to take away and refer back to
• When informing people with breast cancer about the risk of developing lymphoedema, advise them that:
  • lymphoedema can occur in the arm, breast or chest wall
  • they do not need to restrict their physical activity
  • there is no consistent evidence of increased risk of lymphoedema associated with air travel, travel to hot countries, manicures, hot-tub use or sports injuries
  • there is no consistent evidence of increased risk of lymphoedema associated with medical procedures (for example, blood tests, injections, intravenous medicines and blood pressure measurement) on the treated side, and the decision to perform medical procedures using the arm on the treated side should depend on clinical need and the possibility of alternatives
• Give people who have had treatment for breast cancer advice on how to reduce the risk of infection that may cause or exacerbate lymphoedema
• Ensure that people with breast cancer who develop lymphoedema have prompt access to a specialist lymphoedema service. 

Arm and Shoulder Mobility

• Ensure breast care units have documented local guidelines in place for postoperative physiotherapy that have been agreed with the physiotherapy department. Guidelines should cover:
  • details of the upper limb exercises to be carried out after surgical or radiotherapy interventions
  • situations where the exercises should be tailored for individual circumstances and needs
  • who should give information and instructions, and at what points in the person's care this should happen
  • how healthcare staff can best deliver information about the exercises
• Give people who are going to have surgery or radiotherapy for breast cancer instructions and information on upper limb exercises before their treatment begins:
  • explain the benefits of doing the exercises
  • explain when the exercises should be started 
  • ensure the information is in a format suitable for the person to take away to refer to later
  • answer any questions the person may have on the exercises, or how to perform them
  • give details about who to contact if more information is needed. 
    
    Also see the section on communication in the NICE guideline on patient experience in adult NHS services.
• Preoperatively identify people who are having surgery for breast cancer as being at high risk of developing shoulder problems if they have any of the following factors: 
  • any pre-existing shoulder conditions, such as: 
    • history of shoulder surgery 
    • shoulder trauma injury (fracture or shoulder dislocation)
    • frozen shoulder 
    • osteoarthritis or rheumatoid arthritis affecting the shoulder 
    • non-specific shoulder pain
    • stiffness 
    • decreased function 
  • their BMI is >30 kg/m²
  • they have axillary node clearance planned 
  • they have radiotherapy to the axilla or supraclavicular nodes planned
• After surgery, if a person with breast cancer needs previously unplanned axillary node clearance or radiotherapy to the axilla or supraclavicular nodes, identify them as being at high risk
• Offer supervised support when performing upper limb exercises to people who have been identified as being at high risk of developing shoulder problems after surgery for breast cancer (see recommendation above for assessment)
• Consider supervised support when performing upper limb exercises for people who: 
  • are having surgery and have not been identified as being at high risk of developing shoulder problems (as defined by the criteria in the recommendation above), but who may still benefit from supervised support, or
  • are having radiotherapy without surgery
• Ensure supervised support for upper limb exercises: 
  • is available as either individual, group or virtual support, depending on the person's circumstances, needs and preferences
  • is tailored to the person's needs (for example, modifying exercises for people with more complex needs)
  • includes checking that the person is performing the activity correctly
  • is delivered by physiotherapy staff members or other appropriately trained allied health professionals
• Refer people to the physiotherapy department for individual assessment and treatment if they report a persistent reduction in arm and shoulder mobility after breast cancer surgery or radiotherapy.

Menopausal Symptoms

• Offer women information and counselling about the possibility of early menopause and menopausal symptoms associated with breast cancer treatment
• Stop systemic hormone replacement therapy (HRT) in women who are diagnosed with breast cancer
• Do not routinely offer HRT (including oestrogen/progestogen combination) to women with menopausal symptoms and a history of breast cancer.
  
  In June 2023, this was an off-label use of HRT, and HRT is contraindicated in women with a history of breast cancer. See NICE's information on prescribing medicines.
   
• In exceptional circumstances, offer HRT to women with severe menopausal symptoms and a history of breast cancer after a discussion of the associated risks. 
  
  In June 2023, this was an off-label use of HRT, and HRT is contraindicated in women with a history of breast cancer. See NICE's information on prescribing medicines.
   
• Consider selective serotonin reuptake inhibitor (SSRI) antidepressants for women with breast cancer for relieving menopausal symptoms, particularly hot flushes, but not for those taking tamoxifen. For guidance on safe prescribing of antidepressants (such as SSRIs) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
  
  In June 2023, this was an off-label use of SSRIs. See NICE's information on prescribing medicines.
   
• Do not offer soy (isoflavone), red clover, black cohosh, vitamin E or magnetic devices to treat vasomotor symptoms in women with breast cancer.

Follow-up

Follow-up Imaging

• Offer annual mammography for 5 years to all people who have had or are being treated for breast cancer, including DCIS. For women, continue annual mammography past 5 years until they enter the NHS Breast Screening Programme in England or the Breast Test Wales Screening Programme in Wales
• Do not offer mammography of the ipsilateral soft tissues after mastectomy
• Do not routinely use ultrasound or MRI for post-treatment surveillance in people who have had treatment for invasive breast cancer or DCIS.

Clinical Follow-up

• Ensure all people who have had treatment for breast cancer have an agreed, written care plan, recorded in their notes by a named healthcare professional (or professionals) from the multidisciplinary team. Give a copy to the person and to their GP. The plan should include:
  • designated named healthcare professionals
  • dates for review of any adjuvant therapy
  • details of surveillance mammography
  • signs and symptoms to look for and seek advice on
  • contact details for immediate referral to specialist care
  • contact details for support services, for example, support for people with lymphoedema.

Lifestyle

• Advise people who have had or are being treated for breast cancer that a healthy lifestyle is associated with a lower risk of recurrence, and that this should include:
  • achieving and maintaining a healthy weight (see the NICE guidelines on preventing excess weight gain and obesity)
  • limiting alcohol intake to below 5 units per week
  • regular physical activity (see the NICE guideline on physical activity for adults).
• For guidance on smoking cessation, see the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence.