The diagnosis of breast cancer is based on clinical examination; mammography and ultrasound and pathologic diagnosis by needle biopsy.

Pathological diagnosis with fine needle biopsy or core biopsy preferably should be obtained prior to any surgical procedure.

TNM staging based on H&E staining, standardised grading, description of histological types, resection margins, lymph vascular invasion should be reported.

Determination of oestrogen receptor and progesterone receptor status is mandatory, preferably by immunohistochemistry.

Reports of immunohistochemical results for ER and PR should include the percentage of ER and PR positive cells.

Immunohistochemical determination of HER2 should also be performed.

With ambiguous her2 immunohistochemistry, in situ hybridisation (FISH) to determine HER2 gene amplification should be considered.

Routine staging examinations include physical examination, full blood count, routine chemistry including liver enzymes, alkaline phosphatase, calcium and menopausal status.

Only in high risk patients (N2 >= 4 pos lymph nodes; or T4 tumours; or with laboratory or clinical signs or symptoms suspicious for the presence of metastases) are chest Xray, ultrasound or bone scan appropriate.

History taking, eliciting symptoms and physical examination every 3-6 months for 3 years , then 6-12months for 3 years, then annually with attention paid to long term side-effects (osteoporosis).

Ipsilateral and contralateral radiology every year.

Not routinely recommended for asymptomatic patients: blood counts; chemistry, chest Xray, bone scan, liver ultrasound, chest scans of chest or abdomen and any tumour marker such as CA 153, CEA are not recommended.

Serum tumour markers should be used only as a guide to aid treatment decisions and monitor response of not easily measurable disease in the metastatic breast cancer settings and not for screening or diagnosis.

The proliferation marker Ki-67 provides important prognostic information , particularly for patients with small tumours and no axillary node involvement.

Oestrogen and progesterone receptors and their degree of positive are excellent predictors of response in  all patients (all stages ) with breast cancer and aid the multi-disciplinary team as to which hormonal therapy should be used.

Over-expression of the Her-2/neu protein is associated with poor prognosis and can be used to select patients for trastuzumab (Herceptin) therapy.

The role of systemic chemotherapy has been confirmed in a recent meta-analysis of most subsets of patients with breast cancer.

Anthracycline-containing regemins are superior to non-anthracycline containing regimens.

The addition of the taxanes seems to improve overall survival in node positive disease and in ER/PR negative breast cancers.

To ensure optimal care for all patients a multi-disciplinary approach should be utilised for all patients so as to develop an optimal treatment plan.

Primary chemotherapy is the gold standard for all patients with locally advanced breast cancer.

Primary chemotherapy can be used to facilitate cosmesis and make breast conservation feasible in some patients.

Systemic chemotherapy produces durable remission in some patients with metastatic breast cancer.

Amplification of the Her2/neu is associated with increased aggressiveness of breast cancers. Trastuzumab should be utilised in these patients.

All patients with invasive carcinoma should receive radiation therapy as part of breast conservation therapy.

Patients undergoing intra-operative radiation should be part of a trial.

Patients with implants, collagen vascular disease, very large breasts, locally advanced breast cancers or who have had primary chemotherapy should all see the radiation oncologist as part of the multi-disciplinary team prior to having surgery.

Post – operative radiation to the nodal basins and chest wall is appropriate in all stage 3, stage 2 with 4 or more positive nodes  (1-3 nodes positive conflicting data).

All patients with hormone receptor –positive tumours are candidates for endocrine therapy.

Endocrine therapy  reduces the risk of recurrence and improves overall survival.

Patients with ER/PR negative tumours should not get hormonal therapy.

Hormonal theray should be started once chemotherapy is completed.

Concurrent use of Tamoxifen and radiation therapy is not recommended due to potential risk of lung toxicity.

Aromatase inhibitors are to be used in post menopausal patients.

Aromatase inhibitors instead or in sequence with tamoxifen significantly reduce the risk of recurrence.

Certain subgroups (ER+/PR-; HER2+) seem to have a more marked benefit with aromatase inhibitors.

Breast reconstruction is considered vital to the patients rehabilitation and an intrinsic part of breast cancer treatment (if this is the patients desire).

Immediate reconstruction is and should be available to most patients with breast reconstruction.

Skin sparing mastectomy has proven to be a safe and effective surgical approach  (leaving less than 1% of breast tissue) and facilitating most reconstructive surgical options.

Patients receiving adjuvant radiation therapy or primary chemotherapy should have multidisciplinary discussions so as to ensure the safest reconstructive options are offered to the patient.

Oncology surgery reigns supreme and should not be compromised for the sake of reconstruction.

Implants and expanders are generally not compatible with radiation (should not be placed in a patient who is going to receive radiation therapy).

The type of surgery offered depends on the breast size; tumour size and position; lobular or ductal; whether radiation therapy will be given; and nodal status.

Strict adherence to clear surgical margins.

Clipping of surgical beds in breast conservation.

Use of sentinel lymph node biopsy in node negative cancers and axillary sampling /dissection (>8 lymph nodes) merely for prognostic and treatment guidelines.

Most  premenopausal women.

All tumours greater than 1,5cm cm in women fit  for chemotherapy.

1 lymph node or more positive disease.

Tumours which are hormone receptor negative.

Tumours with aggressive biology (lymph vascular invasion, poorly differentiated.

Any person who has had breast conserving surgery.

Any person who has had a mastectomy and has close margins i.e. margins less than 10mm from the tumour.

Ulcerated or fixed tumours which are not surgically resectable in patients who are not fit for chemotherapy.

Any person who has a locally advanced breast cancer.

4 or more lymph nodes positive.

Oncology surgery principles must apply.

Don’t place prostheses or expanders should radiation be needed.

Latissimus flaps are the flap of choice to radiate on.

Careful pre-operative planning.

Accurate radiological marking of the tumour prior to starting chemotherapy with placement of a radio-opaque marker.

Pathological information (core biopsy) with grading ; receptors and Her2 status.

Nodal information from radiology (ultrasound); pathology (FNA or SLNB) prior to staring chemotherapy.

Clinical and radiological follow-up to assess response.

Although SLNB has shown to be accurate in some studies a partial axillary sampling with the SLNB is advised should radiation decision need to be made.