Clinics (see definition in Section 4). Consultations for Breast
patients should be held separately, i.e., not as a part of general surgery.
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
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.
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
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
-one for post-operative consideration of prognosis and adjuvant therapies and
for cases investigated for disease recurrence (oncologists, surgeons,
radiologists and pathologists).
Physiotherapy must be available for the post-operative recovery period to
ensure good shoulder mobility, etc.
-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.
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
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.
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.
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.
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.
(See 8.2 below).
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.
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.