Early and locally advanced breast cancer Nb numbers in brackets denote relevant paragraphs in the breast cancer service guidance Recovery Package: Whole needs assessment. A treatment summary (including surveillance programme) sent to the patient and their GP. Information on likely side-effects of treatment and how best to manage these. Information on potential symptoms of recurrence/secondary cancers and what to do in these occurrences. Key contact point for rapid re-entry if symptoms of recurrence are experienced or if serious side effects become apparent. Access to a patient education and support event, such as a Health and Wellbeing Clinic, to prepare the person of the transition to supported self-management, including advice on healthy lifestyle and physical activity. Referral to a health trainer is often helpful. Signposting to rehabilitation, work and financial support services. Advanced disease (please see metastatic breast cancer pathway) No cancer- reassure discharge Staging tests (imaging) (3.2.2) 1st OPA: Triple Assessment Examination Mammogram/ ultrasound of breast and axilla Biopsy (3.2.1) 2nd OPA: Surgical, ER and HER2 receptor results (3.2.3) Surgery: Wide local excision or mastectomy +/- reconstruction and axillary staging or treatment (3.2.18-3.2.25) GP Referral Stratified Open Access Follow up (3.2.54, appendix 5) Neo adjuvant systemic therapy: Chemotherapy +/- Biological therapy or endocrine therapy (3.2.16, 3.2.17) Holistic Needs Assessment and access to a CNS (3.2.8, 3.2.9) Adjuvant therapy: Endocrine +/- Chemotherapy +/- Anti-HER2 therapy +/- Radiotherapy +/- Biological therapy +/- consider clinical trial (3.2.26-3.2.44, appendix 4) Consider clinical trial (3.2.7, 3.2.52) Recovery Package at end of acute treatment (3.2.45, 3.2.53 and above) Screening Breast MDT (weekly) (3.2.5, 3.2.6) MDT (post-operative results) Cure – 75% Family History Advanced/metastatic disease – 25% (please see metastatic breast cancer pathway) Mammographic surveillance (3.2.55) Consider clinical trial (3.2.7, 3.2.52) A&E Areas covered by breast cancer service guidance Abbreviations: A&E – Accident and Emergency CNS – Clinical Nurse Specialist ER – Oestrogen Receptor GP – General Practitioner HER2 – Human Epithelial Growth Factor receptor OPA = Outpatient Appointment MDT – Multidisciplinary team Key: = Primary care = Secondary care Breast Cancer Clinical Reference Group, October 2015

Metastatic breast cancer Nb numbers in brackets denote relevant paragraphs in the breast cancer service guidance 1st OPA: Triple assessment (if not previously done) (3.2.1, 3.2.48) Holistic needs assessment by specialist metastatic cancer nurse (3.2.47, 3.2.51) Palliative Endocrine therapy +/- Chemotherapy +/- Anti-HER2 therapy +/- Radiotherapy +/- Biological therapy +/- Surgery +/- Bisphosphonates (3.2.49, 3.2.50) Health needs assessment by specialist metastatic cancer nurse (3.2.47, 3.2.51) Consider clinical trial (3.2.52) OPA attendance and monitoring scans 2nd and subsequent lines of systemic therapy (3.2.49, 3.2.50) Recurrence Breast MDT (3.2.46) 2nd OPA: Treatment plan Disease progression End of life care Staging: Imaging and biopsy of primary or metastases (3.2.2) First presentation Palliative care as and when appropriate Areas covered by breast cancer service guidance Key: = Secondary care Abbreviations: OPA = Outpatient Appointment MDT – Multidisciplinary team Breast Cancer Clinical Reference Group, October 2015