Surgery is usually the first treatment option for early breast cancer (DCIS and invasive breast cancer). Pre-operative assessment of the breast and axilla determines the size of the primary tumour relevant to the volume of breast and this information is used to decide whether or not wide local excision (WLE) of the tumour (‘lumpectomy’) is possible, allowing breast-conserving surgery (BCS) instead of mastectomy (removal of the breast). Patients who have a mastectomy can have immediate breast reconstruction (carried out at the same time as the mastectomy) or delayed breast reconstruction.
Pre-operative assessment of the axilla includes ultrasound to determine whether or not morphologically abnormal lymph nodes are present. If abnormal lymph nodes are identified, ultrasound-guided needle biopsy is offered to obtain a tissue sample for testing. If there is no evidence of lymph node involvement on ultrasound, or the ultrasound-guided needle biopsy outcome is negative, lymph node clearance is not performed during BCS. The NICE guideline Early and Locally Advanced Breast Cancer: Diagnosis and Treatment11recommends, instead, sentinel lymph node biopsy (SLNB) as the preferred technique
(SLNB was undertaken for 84% of invasive breast cancers identified during breast cancer screening between April 2011 and March 201242). The tissue from SLNB has typically been analysed using post-operative
histopathology with a 5–15-day wait for results. If macrometastases (tumour deposits with at least one dimension over 2 mm) are identified, a second operation takes place to remove the remaining axillary lymph nodes (axillary lymph node dissection).43In August 2013, NICE recommended whole lymph node analysis
using the RD-100i one-step nucleic acid amplification (OSNA) system as an option for detecting sentinel lymph node metastases. This analysis is carried out during breast surgery, takes approximately 30 to 45 minutes and means that, if the result is positive for metastases (cytokeratin-19 gene expression identified which is a marker associated with breast cancer), axillary lymph node dissection can be completed during the initial surgery, removing the need for a second operation.43The advisory group for this assessment indicated that there are
22 RD-100i OSNA systems currently in use in the UK and use is increasing.
After surgical removal of the primary tumour (and axillary lymph nodes if indicated), the information on prognostic and predictive factors obtained by histological examination, the outcome of tests for ER and HER-2 status, and other patient and tumour characteristics are used by the breast cancer multidisciplinary team to consider options for adjuvant therapy for all patients with early breast cancer. Decisions regarding adjuvant therapy are made following discussion with the patient.44Adjuvant chemotherapy or radiotherapy
should start as soon as clinically possibly and within 31 days of being‘fit to treat’ after surgery.45,46
Data from the NHS Breast Screening Programme Audit 2011–1242indicate that, in practice, some trusts are
struggling to meet this 31-day standard for radiotherapy. Overall, 57% of women received radiotherapy within 60 days and 92% within 90 days of their final surgery.42Advice from the advisory group for this
assessment suggested that the figures for symptomatic cancer (i.e. not screen detected) were likely to be similar and that meeting the 31-day goal for adjuvant chemotherapy may also be difficult.
The range of recommended breast cancer treatment options described by the 2009 NICE guideline Early and Locally Advanced Breast Cancer: Diagnosis and Treatment11are summarised in Table 5.
After BCS, whole-breast external beam radiotherapy (WB-EBRT) substantially reduces the risk of recurrence (15.7% absolute reduction in 10-year risk of any first recurrence) and moderately reduces the risk of breast cancer death (3.8% absolute reduction in 15-year risk of breast cancer death) for patients with early invasive breast cancer.47Therefore, post-operative WB-EBRT is the standard of care for all patients with
early invasive breast cancer after breast-conserving therapy (as per the 2009 NICE guideline11). WB-EBRT
works by directing a beam, or multiple beams, of radiation through the skin directly at the tumour and surrounding cancer cells to destroy them. The radiation beam is generated by an instrument, known as a linear accelerator, which is capable of producing high-energy X-rays or electrons. The most common types of external radiotherapy use photon beams (as X-rays).48From the patient’s perspective, external
radiotherapy is similar to having an X-ray, only the radiation is more intense. In the UK, a hypofractionated regimen is standard practice, with NICE guidelines recommending that patients with early invasive breast cancer who have undergone BCS receive 40 Gy in 15 fractions.11The 15 fractions are typically delivered to
patients by hospital radiotherapy departments at short (10–15-minute) treatment sessions each day, Monday to Friday, with a rest at the weekends. The course is usually given for 3 weeks, but may last longer. This course of radiotherapy can be followed by a‘boost’ dose (e.g. 12 Gy in four fractions, 10 Gy in five fractions or 16 Gy in eight fractions) to the tumour bed over a further 1–2 weeks in patients considered to be at a higher risk of local recurrence (e.g. aged< 40 years, grade 3 disease and lymph node positive).11In many other parts of the world standard practice for whole-breast radiotherapy is 50 Gy
in 25 fractions given daily (Monday to Friday) over 5 weeks.49For patients with apparently localised DCIS
treated with BCS, there is a 25% risk of a local recurrence over 10 years if there is no further therapy and half of the recurrences will be of invasive cancer.11Unfortunately, there is no reliable way to identify the
patients who will not be at risk of local recurrence.50Therefore, adjuvant radiotherapy should be offered to
all patients with DCIS following BCS alongside a discussion of the potential benefits and risks.11
The treatment schedule described above can be difficult for some women to undertake (e.g. if they live a long way from their nearest treatment centre, if they have caring responsibilities, if they are elderly and/or disabled). Whole-breast radiotherapy may also be associated with short-term adverse effects (e.g. skin soreness/redness, tiredness, nausea) as well as long-term adverse effects (e.g. changes to breast size and texture/feel, lung or heart problems), and can be impossible to deliver effectively in patients who are unable to lie flat or in those unable to raise the shoulder on the side receiving treatment.
When chemotherapy is indicated, WB-EBRT is nearly always given when chemotherapy has been completed and after a gap of 2–3 weeks that minimises overlapping and/or enhancing toxicities. For patients who require biological therapy or endocrine therapy, this is typically administered concurrently with WB-EBRT.
Radiotherapy is viewed as a cost-effective treatment. The total spend on radiotherapy (not limited to breast cancer) has been estimated to constitute just 5% of the estimated total NHS spend on cancer care.45
TABLE 5 Non-surgical treatment options for early breast cancer
Adjuvant treatment Treatment options Comments
Radiotherapy Whole-breast radiotherapy following BCS
Post-mastectomy radiotherapy to chest wall
For example, if at high risk of local recurrence
Boost to tumour bed following BCS For example, if at high risk of local recurrence Radiotherapy to nodal areas For example, if four or more involved axillary
lymph nodes
Systemic therapy for metastatic disease
Endocrine therapy For example, tamoxifen or aromatase inhibitor for ER-positive tumours only
Chemotherapy For example, anthracycline-containing regimens, docetaxel
Biological therapy For example, trastuzumab (Herceptin®, Roche)
May need assessment and treatment for bone loss
Primary systemic therapy
Chemotherapy Before surgery, e.g. to shrink tumour before surgery, to observe response in the primary tumour before its surgical removal