Synopsis
Stage operable invasive breast cancer accurately, integrate histology and ER, HER2 and genomic risk, choose breast and axillary treatment and deliver risk-adapted systemic, radiation and survivorship care.
- Early breast cancer is operable invasive disease without distant metastasis; curative planning integrates tumour size, nodes, grade, subtype, comorbidity and patient priorities.
- Core pathology should report invasive type and grade and test oestrogen receptor and HER2; progesterone receptor and proliferation or genomic tests add selected prognostic or predictive information.
- Do not perform routine CT, bone scan or PET-CT for every asymptomatic small node-negative cancer; stage systemically when symptoms, examination, laboratory results or higher anatomical burden makes metastasis plausible.
- Breast-conserving surgery with clear margins followed by appropriate radiotherapy gives survival comparable to mastectomy for suitable tumours; the operations differ in local anatomy, not inherent cancer seriousness.
- Sentinel lymph-node biopsy is the preferred surgical axillary staging method for clinically and ultrasound node-negative invasive cancer, reducing lymphoedema compared with routine clearance.
- Use neoadjuvant systemic treatment when tumour shrinkage may enable breast conservation, when nodal response guides surgery or when response will direct later HER2-positive or triple-negative therapy.
- ER-positive disease needs adjuvant endocrine treatment chosen by menopausal status and recurrence risk; adherence over years is clinically important.
- HER2-positive disease usually receives HER2-directed therapy with chemotherapy according to stage and response, with baseline and serial left-ventricular assessment.
- Chemotherapy benefit is greatest with high-risk biology; validated tumour-profiling assays can support selected ER-positive, HER2-negative decisions but do not replace clinicopathological judgment.
- Radiotherapy is standard after breast conservation and is selected after mastectomy according to tumour, margin and nodal risk; hypofractionated schedules are commonly preferred.
- Offer fertility, contraception, bone, menopausal, cardiovascular, employment and psychosocial planning before treatment creates irreversible effects.
- Follow-up combines treatment-toxicity review, planned mammography and rapid investigation of new symptoms rather than routine whole-body scans in asymptomatic survivors.
Key red flags
A rapidly expanding postoperative breast or axillary swelling, hypotension, severe pain or drain output suggests haemorrhage requiring urgent surgical review.
Fever or systemic deterioration during cytotoxic treatment is neutropenic sepsis until assessed and must not wait for the neutrophil result.
New dyspnoea, pleuritic pain, syncope or unilateral leg swelling during cancer treatment raises venous thromboembolism.
New orthopnoea, oedema or reduced exercise tolerance during anthracycline or HER2 therapy requires prompt cardiac evaluation.
Persistent focal bone pain, neurological symptoms, jaundice or unexplained respiratory change after early cancer treatment may represent recurrence and requires investigation between routine visits.
Persistent bone pain, neurological change, respiratory symptoms, hepatomegaly or abnormal liver and calcium results requires systemic staging before a purely local plan.
Investigation priorities
Confirm invasion, histological type and grade and identify the principal predictive treatment targets.
Define multifocality, extent and contralateral disease and identify nodes requiring preoperative sampling.
Management branches
Biopsy confirms invasive cancer that is suitable for primary surgery.
- Map tumour extent, breast-to-tumour ratio, genetics, radiotherapy feasibility, reconstruction and preference and compare breast conservation with mastectomy using equivalent-survival information where appropriate.
- Stage a clinically and ultrasound node-negative axilla with sentinel-node biopsy and plan targeted or more extensive axillary treatment only when nodal findings justify the additional morbidity.
- Review final tumour size, type, grade, margins, lymphovascular invasion, nodes and biomarkers at the MDT and arrange re-excision, radiation and systemic treatment from the complete risk profile.