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Breast Unit Guidelines

The requirements of a specialist breast unit

7. Facilities/Services

Clinics (see definition in Section 4). Consultations for Breast patients should be held separately, i.e., not as a part of general surgery.

7.1

New patient clinics
At least one clinic per week for newly referred symptomatic women must be held. A Unit diagnosing 150 new cancers per year must expect over 1500 new referrals of symptomatic women (=approximately 30 per week).
A suggested good practice is that all newly referred women with breast symptoms should be offered an appointment within 10 working days of receipt of the referral.
Clinics to which patients are referred or self-referred must be staffed by a surgeon, a radiologist and radiographers from the breast care team. Multidisciplinary working must allow all standard investigations for triple assessment (clinical examination and all appropriate imaging and tissue diagnostic procedures) to be completed at one visit. Where possible the finding of no abnormality or the diagnosis of a benign lesion should be communicated to the patient at that visit.

7.2

Communication of the Diagnosis and Treatment Plan
It may not be possible (now that core biopsy is most often used) or may not be considered appropriate by the unit to give the diagnosis of cancer at the initial visit. Women found to have breast cancer should receive that diagnosis within 5 working days. The diagnosis should be ideally communicated personally by the surgeon: if it is communicated by the radiologist, then the surgeon (±) the oncologist must personally advice the patient on treatment. It is recommended that a breast care nurse (or) psychologically trained person (see 5.2.8) be present to discuss fully with the patient the options for treatment and to give emotional support. If a patient has clear advanced breast cancer it may be more appropriate that an oncologist rather than a surgeon gives the diagnosis if the patient's treatment does not involve surgery.
A suitable room with sufficient privacy must be available. In units in which preoperative irradiation or primary medical therapies are used, cases which might be suitable for these should be seen jointly by a surgeon and radiation or medical oncologist before treatment commences.
A diagnosis should not be given to a patient by letter or on the telephone, unless at the specific request of the patient given adequate and full informed choice.

7.3

Multidisciplinary Case Management Meetings (MDM's)
All members of the core team must attend the Multidisciplinary Meeting (MDM), which must be held at least weekly.
The following should be discussed:
-cases in which the diagnosis is as yet uncertain e.g., following core biopsy
-cases in whom the diagnosis of cancer is confirmed and who may be considered for primary medical therapy
-all cases following surgery on receipt of the histopathology for discussion of further care and
-cases in follow-up who recently have undergone diagnostic investigations for possible symptoms of recurrent or advanced disease
It is possibly more convenient to have two MDM's per week:
-one for cases in diagnosis attended by surgeons, radiologists and pathologists and
-one for post-operative consideration of prognosis and adjuvant therapies and for cases investigated for disease recurrence (oncologists, surgeons, radiologists and pathologists).

7.4

Physiotherapy
Physiotherapy must be available for the post-operative recovery period to ensure good shoulder mobility, etc.

7.5

Adjuvant Therapies
-The multidisciplinary team (MDT) must decide on the appropriate adjuvant therapies in light of the pathology of the surgical specimen.
-Radiotherapy may be delivered within the same hospital or patients may have to travel to a Radiotherapy Unit in another Hospital (at which the core team radiation oncologist must be able to supervise their treatment).
-The administration of cytotoxic therapy as adjuvant therapy or for advanced disease must be by an accredited oncologist (member of the core team) with proper facilities. Cytotoxic therapies may be given in another hospital but the decisions regarding their application must be made by the MDT of the Unit.

7.6

Advanced and Recurrent Breast Cancer
-There must be one Advanced Breast Cancer Clinic at least every 2 weeks at the Breast Unit, separate from the general oncology clinics (although sometimes combined with gynaecological oncology) and attended by the Clinical Oncologist ± Medical Oncologist (see 5.2.5 b). The surgeon must be available if required for consultation and must be in full attendance if the breast surgeons supervise the endocrine therapies. Patients with distant metastases, locally advanced primary breast cancer and local or regional recurrence, must be managed in this clinic according to protocols agreed by the multidisciplinary team.
Patients who have received radiotherapy or chemotherapy at another Cancer Centre should normally be referred back to the Breast Team at their Breast Unit for further follow-up and decision making in the Advanced Breast Cancer Clinic.
-A palliative care/pain control service must be easily accessible.

7.7

Follow-up of primary breast cancer
-All patients with primary breast cancer must be followed-up in a Clinic directly supervised by one of the surgeons. Any necessary imaging or other investigations should be carried out at the same visit.
-Although the patient may have to visit a separate Hospital to receive radiotherapy or specialised chemotherapy, the decisions on the case management and the subsequent follow-up should be by the team members of her Breast Unit. The skills of the diagnostic breast team are then available for the detection and investigation of a possible recurrence.

7.8

Benign disease
The Breast Unit must also advise and where necessary treat women with benign disease (e.g.) cysts, fibroadenoma, mastalgia, inflammatory conditions, mammillary fistula and phyllodes tumour.

7.9

Family History/genetics
Advice is best given in a multidisciplinary clinic, the specialists involved are a clinical geneticist and from the team a breast surgeon with reconstructive skills, radiologist and psychiatrist or clinical psychologist. Gene probing must be available when required and ideally a molecular geneticist should be accessible for consultation by the specialists in the clinic.

7.10

Reconstruction
(See 8.2 below).

7.11

Breast Screening
Ideally breast screening centres should be a part of Breast Units and the same radiologists should be members of the Unit team and work in screen detection and the diagnosis of symptomatic disease. Assessment centres should be placed in Breast Units.

7.12

Patient Information
Women must be offered clear written and oral information regarding their diagnosis and/or treatment options. The Breast Unit should also provide written information concerning local out patient support groups and advocacy organisations and should also respect the patients rights as outlined in the Breast Cancer Resolution of the European Parliament (OJ C 68 E (18.03.2004), p.611). Patients should be provided with a list of their rights as outlined in the breast cancer resolution.


Please use this address to send us any comments you want to make on the guidelines - we welcome your feedback: information@eusoma.org

 



San Antonio Breast Cancer Symposium. 5th-9th December 2017 , San Antonio,Texas,USA

San Antonio
Breast Cancer Symposium
5th-9th December 2017
San Antonio,Texas,USA


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