5th March 2009
NICE has issued two clinical guidelines on management of breast cancer. Clinical Guideline 80 covers the tests and treatments that should be offered to patients with early and locally advanced breast cancer, whereas Clinical Guideline 81 describes the tests, treatment, care and support that patients with advanced breast cancer should be offered.
The quick reference guides for CG80 and CG81 should be read by those involved in the care of people with breast cancer. Specialist staff will of course need to be familiar with the whole guidelines (CG80, CG81).
The clinical guideline for early and locally advanced cancer includes recommendations on assessment and diagnosis; treatments to reduce the amount of surgery under the arm; breast reconstruction when breast conservation is not possible; and adjuvant therapies, including radiotherapy, chemotherapy, endocrine treatments and biological treatments. This guideline updates and replaces NICE technology appraisal guidance 109 (docetaxel), 108 (paclitaxel) and 107 (trastuzumab▼).
The clinical guideline for advanced cancer includes recommendations for diagnosis and assessment; use of disease modifying therapies, including endocrine therapy, chemotherapy and biological therapy; supportive care; and the management of complications, including the use of bisphosphonates in patients with bone metastases. This guideline updates and replaces NICE technology appraisal guidance 62 (capecitabine), 54 (vinorelbine) and 30 (taxanes).
Key implementation priorities involving drug treatment
Among the key implementation priorities in the clinical guideline for early and locally advanced cancer are the following recommendations:
- Adjuvant therapy planning — Start adjuvant chemotherapy or radiotherapy as soon as clinically possible within 31 days of completion of surgery in patients with early breast cancer having these treatments.
- Aromatase inhibitors — Postmenopausal women with oestrogen receptor (ER)-positive early invasive breast cancer who are not considered to be at low risk should be offered an aromatase inhibitor, either anastrozole or letrozole, as their initial adjuvant therapy. Offer tamoxifen if an aromatase inhibitor is contraindicated or not tolerated.
- Primary systemic therapy — Treat patients with early invasive breast cancer, irrespective of age, with surgery and appropriate systemic therapy, rather than endocrine therapy alone, unless significant comorbidity precludes surgery.
Among the key implementation priorities in the clinical guideline for advanced cancer are the following recommendations:
- Offer endocrine therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer.
- For patients with advanced breast cancer who are not suitable for anthracyclines (because they are contraindicated or because of prior anthracycline treatment either in the adjuvant or metastatic setting), systemic chemotherapy should be offered in the following sequence:
- – First line — single-agent docetaxel
- – Second line — single-agent vinorelbine or capecitabine
- – Third line — single-agent capecitabine or vinorelbine
(whichever was not used as second-line treatment).
- For patients who are receiving treatment with trastuzumab▼ for advanced breast cancer, discontinue treatment with trastuzumab▼ at the time of disease progression outside the central nervous system. Do not discontinue trastuzumab▼ if disease progression is within the central nervous system alone.