Early and locally advanced breast cancer: diagnosis and management

Offer genetic testing for BRCA1 and BRCA2 mutations to women under 50 years with triple-negative breast cancer, including those with no family history of breast or ovarian cancer (also see the recommendations on genetic testing in the NICE guideline on familial breast cancer). [2017]

Offer breast-conserving surgery with removal of the nipple–areolar complex as an alternative to mastectomy for people with Paget's disease of the nipple that has been assessed as localised. Offer oncoplastic repair techniques to maximise cosmesis. [2009]

Offer further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery where invasive cancer or DCIS is present at the radial margins ('tumour on ink'; 0 mm). [2018]

Consider further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery for DCIS without invasive cancer if tumour cells are present within 2 mm of, but not at, the radial margins (greater than 0 mm and less than 2 mm). As part of the decision making:

• discuss the benefits and risks with the person

• take into account:

  • the person's circumstances, needs and preferences

  • any comorbidities

  • tumour characteristics and potential treatments, including the use of radiotherapy (also see radiotherapy after breast-conserving surgery) and other adjuvant therapies. [2024]

Consider further surgery (re-excision or mastectomy, as appropriate) after breast-conserving surgery for invasive cancer with or without DCIS if tumour cells are present within 1 mm of, but not at, the radial margins (greater than 0 mm and less than 1 mm). As part of the decision making:

• discuss the benefits and risks with the person

• take into account:

  • the person's circumstances, needs and preferences

  • any comorbidities

  • tumour characteristics and potential treatments, including the use of radiotherapy (also see radiotherapy after breast-conserving surgery) and other adjuvant therapies. [2024]

When discussing the benefits and risks of further surgery, follow the recommendations on:

• enabling patients to actively participate in their care in NICE's guideline on patient experience in adult NHS services and

• communicating risks, benefits and consequences in NICE's guideline on shared decision making. [2024]

Do not routinely perform SLNB for women with a preoperative diagnosis of DCIS who are having breast-conserving surgery, unless they are considered to be at high risk of invasive disease. People at high risk of invasive disease include those with a palpable mass or extensive microcalcifications. [2009]

Offer SLNB to all people who are having a mastectomy for DCIS. [2009]

Perform surgery using sentinel lymph node biopsy (SLNB) rather than axillary lymph node clearance to stage the axilla for people with invasive breast cancer if they have:

• no evidence of lymph node involvement on ultrasound or

• a negative ultrasound-guided needle biopsy. [2009, amended 2023]

Perform SLNB using the dual technique with isotope and blue dye. [2009]

Offer axillary node clearance to people with invasive breast cancer who have a preoperative ultrasound-guided needle biopsy with pathologically proven lymph node metastases. [2009, amended 2018]

Offer further axillary treatment (axillary node clearance or radiotherapy) after SLNB to people who have 1 or more sentinel lymph node macrometastasis. [2018]

Discuss the benefits and risks of not having further axillary treatment after primary breast-conserving surgery (within clinical trials where available) with women who:

• have 1 or 2 sentinel lymph node macrometastases and

• have been advised to have whole-breast radiotherapy with systemic therapy (which may be endocrine therapy). [2018]

Do not offer further axillary treatment to people who only have micrometastases in their sentinel lymph nodes after primary surgery for invasive breast cancer. [2018]

Do not offer further axillary treatment to people who have isolated tumour cells in their sentinel lymph nodes after primary surgery for invasive breast cancer. Classify this as lymph node-negative breast cancer. [2018]

All breast units should audit their local, regional and distant recurrence rates after treatment, including systematically collecting data on radial margins and demographic information (such as socioeconomic status, age and ethnicity). [2009, amended 2024]

Breast units should audit their axillary recurrence rates. [2009]

For people with breast cancer where adjuvant chemotherapy is indicated, offer a regimen that contains both a taxane and an anthracycline. [2018, amended 2023]

Discuss with people the benefits and risks of adding a taxane to anthracycline-containing regimens for adjuvant chemotherapy. Topics to discuss include those in table 2 and:

• the benefits of reduced cardiac toxicity and reduced nausea

• the risks of additional side effects, including neuropathy, neutropenia and hypersensitivity

• the different side effects and dosing frequencies of different docetaxel and paclitaxel regimens, and the additional clinic visits that may be needed

• that absolute benefit is proportional to absolute risk of recurrence. [2018]

Ensure weekly and fortnightly paclitaxel is available locally, as it is better tolerated than 3-weekly docetaxel, particularly in people with comorbidities. [2018, amended 2023]

Where neoadjuvant chemotherapy is indicated for people with triple-negative invasive breast cancer, offer a regimen that contains a platinum, a taxane and an anthracycline. Discuss the benefits and risks of this approach (see table 3), taking into account the person's circumstances, needs and preferences. [2025]

Pembrolizumab is recommended as an option in NICE technology appraisal guidance with chemotherapy for neoadjuvant treatment then continued alone as adjuvant treatment of triple-negative locally advanced breast cancer or early breast cancer at high risk of recurrence. For full details, see the guidance on pembrolizumab (TA851, 2022).

Olaparib, alone or with endocrine therapy, is recommended as an option in NICE technology appraisal guidance for the adjuvant treatment of HER2‑negative high-risk early breast cancer that has been treated with neoadjuvant or adjuvant chemotherapy in adults with germline BRCA1 or 2 mutations. For full details, see the guidance on olaparib (TA886, 2023).

For people with HER2-positive invasive breast cancer offer neoadjuvant chemotherapy where indicated and in line with the commissioning criteria for any related technology appraisal guidance. [2025]

Pertuzumab in combination with trastuzumab is recommended as an option in NICE technology appraisal guidance for treating HER2-positive breast cancer in adults that is locally advanced, inflammatory, or early-stage with a high risk of recurrence. For full details, see the guidance on pertuzumab (TA424, 2016).

Trastuzumab emtansine is recommended as an option in NICE technology appraisal guidance for adjuvant treatment of HER2-positive early breast cancer if there is residual invasive disease in the breast or lymph nodes after neoadjuvant taxane-based and HER2-targeted therapy. For full details, see the guidance on trastuzumab emtansine (TA632, 2020).

Pertuzumab with trastuzumab and chemotherapy is recommended as an option in NICE technology appraisal guidance for adjuvant treatment of HER2-positive early breast cancer only if there is lymph node-positive disease. For full details, see the guidance on pertuzumab (TA569, 2019).

Offer adjuvant trastuzumab for people with T1c and above HER2-positive invasive breast cancer. Give this at 3-week intervals for 1 year in combination with surgery, chemotherapy, endocrine therapy and radiotherapy, as appropriate. [2009, amended 2023]

Consider adjuvant trastuzumab for people with T1a/T1b HER2-positive invasive breast cancer, taking into account any comorbidities, prognostic features, possible toxicity of chemotherapy and the person's preferences. [2018]

Use trastuzumab with caution in people with HER2-positive invasive breast cancer if they have any of the following:

• a baseline left ventricular ejection fraction (LVEF) of 55% or less

• a history of, or current, congestive heart failure

• a history of myocardial infarction

• angina pectoris needing medication

• cardiomyopathy

• cardiac arrhythmias needing medical treatment

• clinically significant valvular heart disease

• haemodynamic-effective pericardial effusion

• poorly controlled hypertension. [2009, amended 2018]

Neratinib is recommended as an option in NICE technology appraisal guidance for the extended adjuvant treatment of hormone receptor-positive, HER2-positive early breast cancer in some people who completed adjuvant trastuzumab-based therapy less than 1 year ago. For full details, see the guidance on neratinib (TA612, 2019).

Consider neoadjuvant chemotherapy, where indicated, for people with ER-positive invasive breast cancer. [2018, amended 2025]

Offer neoadjuvant chemotherapy to people with ER-negative PR- positive invasive breast cancer where indicated. [2018, amended 2025

Olaparib, alone or with endocrine therapy, is recommended as an option in NICE technology appraisal guidance for the adjuvant treatment of HER2-negative high-risk early breast cancer that has been treated with neoadjuvant or adjuvant chemotherapy in adults with germline BRCA1 or 2 mutations. For full details, see the guidance on olaparib (TA886, 2023).

Consider neoadjuvant endocrine therapy for postmenopausal women with ER-positive invasive breast cancer as an option to reduce tumour size if there is no definite indication for chemotherapy. [2018]

Advise premenopausal women that neoadjuvant chemotherapy may be more likely to produce a clinical response than neoadjuvant endocrine therapy, but that some tumours do respond to neoadjuvant endocrine therapy. [2018]

Discuss with women the benefits and risks of neoadjuvant endocrine therapy compared with neoadjuvant chemotherapy (see table 4). [2018]

Abemaciclib with endocrine therapy is recommended as an option in NICE technology appraisal guidance for adjuvant treatment of hormone receptor-positive, HER2-negative, node-positive early breast cancer at high risk of recurrence. For full details, see the guidance on abemaciclib (TA810, 2022).

Offer adjuvant endocrine therapy to people with ER-positive invasive breast cancer. [2025]

Make a shared decision with premenopausal or perimenopausal people with ER-positive invasive breast cancer about the type of endocrine therapy that would be suitable for them. As part of this process:

• discuss the benefits and risks of using tamoxifen alone, or ovarian function suppression in combination with tamoxifen, or ovarian function suppression in combination with an aromatase inhibitor (see table 5)

• explain that the use of ovarian function suppression (in combination with tamoxifen or an aromatase inhibitor) may be most beneficial for people who are at higher risk of disease recurrence

• provide information about the potential side effects of each treatment option, including what to expect and how these could be managed if they develop (including possible referral to support services).
  
  See also the recommendations on bone health and menopausal symptoms. [2025]

Offer an aromatase inhibitor as the initial adjuvant endocrine therapy for women and people who are postmenopausal with ER-positive invasive breast cancer who are at medium or high risk of disease recurrence. Offer tamoxifen to women and people who are at low risk of disease recurrence, or if aromatase inhibitors are not tolerated or are contraindicated. [2009, amended 2018]

Offer tamoxifen as adjuvant endocrine therapy for people with ER-positive invasive breast cancer who have male reproductive organs. [2009, amended 2025]

Consider testicular function suppression in combination with an aromatase inhibitor if tamoxifen is not suitable or not tolerated for people with ER-positive invasive breast cancer who have male reproductive organs. [2025]

In March 2025, this was an off-label use for testicular function suppression and aromatase inhibitors. See NICE's information on prescribing medicines.

Do not use an aromatase inhibitor alone in people with ER-positive invasive breast cancer who have male reproductive organs. [2025]

Discuss the benefits and risks of the possible treatment options with people with ER-positive invasive breast cancer who have male reproductive organs. Ensure the discussion covers information about potential side effects of endocrine therapy, including side effects specific to people with male reproductive organs such as erectile dysfunction and gynaecomastia (with testicular function suppression in combination with an aromatase inhibitor) and how support could be accessed if they develop these symptoms. [2025]

On starting testicular function suppression in combination with an aromatase inhibitor, assess bone mineral density in people with ER-positive invasive breast cancer who have male reproductive organs (also see the recommendations in the section on bone health). [2025]

Discuss the benefits and risks of extended endocrine therapy (past the 5-year point) with people who this treatment may be suitable for (see table 6). [2018, amended 2023]

Offer extended endocrine therapy with an aromatase inhibitor for women and people who are postmenopausal with ER-positive invasive breast cancer who are at medium or high risk of disease recurrence and who have been taking tamoxifen for 2 to 5 years. Medium or high risk may include people who have lymph node-positive breast cancer, with tumours that are T2 or greater and higher grade. [2018]

Consider extended endocrine therapy (past the 5-year point) with an aromatase inhibitor for women and people who are postmenopausal with ER-positive invasive breast cancer who are at low risk of disease recurrence and who have been taking tamoxifen for 2 to 5 years. Low risk may include people with lymph node-negative breast cancer, with smaller or lower-grade tumours. [2018]

In March 2025, this was an off-label use for aromatase inhibitors. See NICE's information on prescribing medicines.

Consider extending the duration of tamoxifen therapy for longer than 5 years for people with ER-positive invasive breast cancer. [2018]

Discuss the benefits and risks (see table 7) of endocrine therapy after breast-conserving surgery for women with ER-positive DCIS. [2018]

Offer endocrine therapy after breast-conserving surgery for women with ER-positive DCIS if radiotherapy is recommended but not received. [2018]

Consider endocrine therapy after breast-conserving surgery for women with ER-positive DCIS if radiotherapy is not recommended. [2018]

Offer whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins. [2018]

Consider partial-breast radiotherapy as an alternative to whole-breast radiotherapy for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins and who:

• have a low absolute risk of local recurrence (defined as women aged 50 and over with tumours that are 3 cm or less, N0, ER‑positive, HER2‑negative and grade 1 to 2), and

• have been advised to have adjuvant endocrine therapy for a minimum of 5 years. [2018]

If partial-breast radiotherapy (see recommendation 1.13.4) may be suitable for a woman, discuss the benefits and risks with them and reach a shared decision on its use. Topics to cover include that:

• local recurrence with partial-breast radiotherapy at 5 years is equivalent to that with whole-breast radiotherapy

• the risk of local recurrence beyond 5 years is not yet known

• there is a potential reduction in late adverse effects. [2018, amended 2023]

When giving partial-breast radiotherapy, use external beam radiotherapy. [2018]

Consider not using radiotherapy for women who:

• have had breast-conserving surgery for invasive breast cancer with clear margins and

• have a very low absolute risk of local recurrence (defined as women aged 65 and over with tumours that are T1N0, ER-positive, HER2-negative and grade 1 to 2) and

• are willing to take adjuvant endocrine therapy for a minimum of 5 years. [2018]

When considering not using radiotherapy (see recommendation 1.13.7), discuss the benefits and risks with the woman (see table 8) and explain that:

• without radiotherapy, local recurrence occurs in about 50 women per 1,000 at 5 years, and with radiotherapy, occurs in about 10 women per 1,000 at 5 years

• overall survival at 10 years is the same with or without radiotherapy

• there is no increase in serious late effects if radiotherapy is given (for example, congestive cardiac failure, myocardial infarction or secondary cancer). [2018]

Consider adjuvant radiotherapy for women with DCIS following breast-conserving surgery with clear margins. Discuss the possible benefits and risks of radiotherapy (also see the section on surgery to the breast) and make a shared decision about its use. [2009]

Offer adjuvant postmastectomy radiotherapy to people with node-positive (macrometastases) invasive breast cancer or involved resection margins. [2018]

Consider adjuvant postmastectomy radiotherapy for people with node-negative T3 or T4 invasive breast cancer. [2018]

Do not offer radiotherapy following mastectomy to people with invasive breast cancer who are at low risk of local recurrence (for example, most people who have lymph node-negative breast cancer). [2018, amended 2023]

Offer 26 Gy in 5 fractions over 1 week for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy. [2023]

Consider 40 Gy in 15 fractions over 3 weeks for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy when they:

• have a diagnosis that increases sensitivity to radiotherapy or

• have had implant-based reconstruction or

• have any other factor that could mean having radiotherapy over 3 weeks is more acceptable (such as high body mass index [BMI] or fibromyalgia). [2023]

When discussing the benefits and risks of the 2 regimens, follow the recommendations on:

• enabling patients to actively participate in their care in the NICE guideline on patient experience in adult NHS services and

• communicating risks, benefits and consequences in the NICE guideline on shared decision making. [2023]

Offer 40 Gy in 15 fractions over 3 weeks for people with invasive breast cancer having regional lymph node irradiation, with or without whole-breast or chest-wall radiotherapy, after breast-conserving treatment or mastectomy. [2023]

Offer an external beam boost to the tumour bed for women with invasive breast cancer and a high risk of local recurrence, following whole-breast radiotherapy. [2009, amended 2018]

Inform women of the risk of side effects associated with an external beam boost to the tumour bed following whole-breast radiotherapy. [2009, amended 2018]

Do not offer adjuvant radiotherapy to regional lymph nodes to people with invasive breast cancer who have histologically lymph node-negative breast cancer. [2009, amended 2018]

Do not offer people with invasive breast cancer adjuvant radiotherapy to the axilla after axillary clearance. [2009, amended 2023]

Offer adjuvant radiotherapy to the supraclavicular fossa to people with invasive breast cancer and 4 or more involved axillary lymph nodes. [2009]

Offer adjuvant radiotherapy to the supraclavicular fossa to people with invasive breast cancer and 1 to 3 positive lymph nodes if they have other poor prognostic factors (for example, T3 and/or histological grade 3 tumours) and good performance status. [2009]

Consider including the internal mammary chain within the nodal radiotherapy target for people with node-positive (macrometastases) invasive breast cancer. [2018]

The Intrabeam radiotherapy system for adjuvant treatment of early invasive breast cancer during breast-conserving surgical tumour removal is not recommended in NICE technology appraisal guidance for routine commissioning. Use is recommended only using machines that are already available, and in conjunction with NHS England specified clinical governance, data collection and submission arrangements. For full details, see the guidance on the Intrabeam radiotherapy system (TA501, 2018). [2018]

Offer local treatment with mastectomy (or, in exceptional cases, breast-conserving surgery) followed by radiotherapy to people with locally advanced or inflammatory breast cancer that has been treated with neoadjuvant chemotherapy. [2009]

Offer postmastectomy radiotherapy after neoadjuvant chemotherapy if post-treatment histology shows node-positive (macrometastases) breast cancer or involved resection margins. [2018]

Offer postmastectomy radiotherapy after neoadjuvant chemotherapy if pretreatment investigations show node-positive (macrometastases) breast cancer. [2018]

Consider postmastectomy radiotherapy after neoadjuvant chemotherapy if post-treatment histology shows node-negative T3 breast cancer. [2018]

Consider postmastectomy radiotherapy after neoadjuvant chemotherapy if pretreatment investigations show node-negative T3 breast cancer. [2018]

Inform people having breast cancer treatment about their risk of developing lymphoedema after treatment. Before treatment starts, give them information in a suitable format to take away and refer to. This should include:

• information on:

  • risk reduction strategies, such as maintaining a healthy body weight, ways to reduce their risk of infection, and advice on skincare (for example, use of moisturiser and sunscreen) and physical activity

  • early signs and symptoms, such as signs or sensations of swelling, or signs of infection

  • awareness of skin changes, such as changes in skin colour and appearance of rashes

  • how to self-monitor and identify these signs and symptoms

  • how to collect baseline measurements of the limb.

• that there is no consistent evidence of increased risk of lymphoedema associated with air travel, travel to hot countries, manicures, hot tub use or sports injuries

• that there is no consistent evidence of increased risk of lymphoedema associated with medical procedures (for example, blood tests, injections, intravenous medicines and blood pressure measurement) on the treated side

• who to contact if signs or symptoms develop (see the section on follow-up). [2018, amended 2025]

Make a shared decision on whether to perform medical procedures using the arm on the treated side. Base this on the person's preferences and clinical judgement, taking into account the person's clinical needs and the possibility of alternatives. [2018, amended 2025]

Ensure people who are at risk of, breast-cancer-related lymphoedema are aware that

• physical activity may improve their overall quality of life, and

• there is no indication that physical activity causes, or worsens, lymphoedema.
  
  For advice on a healthy lifestyle, see the section on lifestyle. [2025]

Do not offer compression therapy as a risk-reducing measure to people who are at risk of breast-cancer-related lymphoedema. [2025]

For advice on the use of lymphovenous anastomosis during surgery with special arrangements for clinical governance, consent and audit or research, see the NICE interventional procedures guidance on lymphovenous anastomosis during axillary or inguinal node dissection for preventing secondary lymphoedema. [2025]

Ensure that people with breast cancer who develop lymphoedema are referred to a specialist lymphoedema service for further assessment, and to discuss possible management options (for example, conservative management, surgical options), as soon as possible. [2009, amended 2025]

Discuss the following topics with people with lymphoedema, and also provide them with information in a suitable format to take away and refer to later:

• lymphoedema and its management options

• skin and nailcare to prevent complications of lymphoedema

• support groups

• how to recognise the serious complications of lymphoedema that need urgent medical attention, for example cellulitis or deep vein thrombosis. [2025]

Assess people with lymphoedema for other treatable underlying factors (for example, nodal disease and cellulitis) before starting any lymphoedema management programme. [2025]

Offer compression therapy as the first stage of lymphoedema management. Make a shared decision with the person about the form of compression that is best for them. [2025]

If compression therapy is not appropriate or not comfortable, some people might wish to try kinesiology tape. [2025]

Reassure people that there is no evidence that physical activity (including upper limb exercise) will worsen their lymphoedema and explain that it may improve their overall quality of life. [2025]

Ensure breast care units have documented local guidelines in place for postoperative physiotherapy that have been agreed with the physiotherapy department. Guidelines should cover:

• details of the upper limb exercises to be carried out after surgical or radiotherapy interventions

• situations where the exercises should be tailored for individual circumstances and needs

• who should give information and instructions, and at what points in the person's care this should happen

• how healthcare staff can best deliver information about the exercises. [2023]

Give people who are going to have surgery or radiotherapy for breast cancer instructions and information on upper limb exercises before their treatment begins:

• explain the benefits of doing the exercises

• explain when the exercises should be started

• ensure the information is in a format suitable for the person to take away to refer to later

• answer any questions the person may have on the exercises, or how to perform them

• give details about who to contact if more information is needed.
  
  Also see the section on communication in the NICE guideline on patient experience in adult NHS services. [2023]

Preoperatively identify people who are having surgery for breast cancer as being at high risk of developing shoulder problems if they have any of the following factors:

• any pre-existing shoulder conditions, such as:

  • history of shoulder surgery

  • shoulder trauma injury (fracture or shoulder dislocation)

  • frozen shoulder

  • osteoarthritis or rheumatoid arthritis affecting the shoulder

  • non-specific shoulder pain

  • stiffness

  • decreased function

• their BMI is over 30 kg/m²

• they have axillary node clearance planned

• they have radiotherapy to the axilla or supraclavicular nodes planned. [2023]

After surgery, if a person with breast cancer needs previously unplanned axillary node clearance or radiotherapy to the axilla or supraclavicular nodes, identify them as being at high risk. [2023]

Offer supervised support when performing upper limb exercises to people who have been identified as being at high risk of developing shoulder problems after surgery for breast cancer (see recommendation 1.12.7 for assessment). [2023]

Consider supervised support when performing upper limb exercises for people who:

• are having surgery and have not been identified as being at high risk of developing shoulder problems (as defined by the criteria in recommendation 1.12.7), but who may still benefit from supervised support or

• are having radiotherapy without surgery. [2023]

Ensure supervised support for upper limb exercises:

• is available as either individual, group or virtual support, depending on the person's circumstances, needs and preferences

• is tailored to the person's needs (for example, modifying exercises for people with more complex needs)

• includes checking that the person is performing the activity correctly

• is delivered by physiotherapy staff members or other appropriately trained allied health professionals. [2023]

Refer people to the physiotherapy department for individual assessment and treatment if they report a persistent reduction in arm and shoulder mobility after breast cancer surgery or radiotherapy. [2023]

Offer women information and counselling about the possibility of early menopause and menopausal symptoms associated with breast cancer treatment. [2009]

Stop systemic hormone replacement therapy (HRT) in women who are diagnosed with breast cancer. [2009]

Do not routinely offer HRT (including oestrogen/progestogen combination) to women with menopausal symptoms and a history of breast cancer. [2009, amended 2023]

In March 2025, this was an off-label use of HRT, and HRT is contraindicated in women with a history of breast cancer. See NICE's information on prescribing medicines.

In exceptional circumstances, offer HRT to women with severe menopausal symptoms and a history of breast cancer after a discussion of the associated risks. [2009, amended 2023]

In March 2025, this was an off-label use of HRT, and HRT is contraindicated in women with a history of breast cancer. See NICE's information on prescribing medicines.

Consider selective serotonin reuptake inhibitor (SSRI) antidepressants for women with breast cancer for relieving menopausal symptoms, particularly hot flushes, but not for those taking tamoxifen. For guidance on safe prescribing of antidepressants (such as SSRIs) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms. [2009, amended 2018]

In March 2025, this was an off-label use of SSRIs. See NICE's information on prescribing medicines.

Do not offer soy (isoflavone), red clover, black cohosh, vitamin E or magnetic devices to treat vasomotor symptoms in women with breast cancer. [2009, amended 2023]

Offer a baseline dual-energy X-ray absorptiometry (DEXA) scan to assess bone mineral density in women with invasive breast cancer who are not receiving bisphosphonates as adjuvant therapy and who:

• are starting adjuvant aromatase inhibitor treatment or

• have treatment-induced menopause or

• are starting ovarian ablation/suppression therapy. [2009, amended 2018]

Do not offer a DEXA scan to people with invasive breast cancer who are receiving tamoxifen alone. [2009, amended 2023]

Offer bisphosphonates to women identified by algorithms 1 and 2 in the guidance for the management of breast cancer treatment‑induced bone loss: a consensus position statement from a UK expert group (2008; this guidance is not NICE-accredited). [2009]

Offer annual mammography for 5 years to all people who have had or are being treated for breast cancer, including DCIS. For women, continue annual mammography past 5 years until they enter the NHS Breast Screening Programme (NHSBSP) in England or the Breast Test Wales Screening Programme (BTWSP) in Wales. [2009, amended 2023]

Do not perform mammography of the ipsilateral soft tissues after mastectomy. [2009]

Do not routinely use ultrasound or MRI for post-treatment surveillance in people who have had treatment for invasive breast cancer or DCIS. [2009, amended 2023]

Ensure all people who have had treatment for breast cancer have an agreed, written care plan, recorded in their notes by a named healthcare professional (or professionals) from the multidisciplinary team. Give a copy to the person and to their GP. The plan should include:

• designated named healthcare professionals

• dates for review of any adjuvant therapy

• details of surveillance mammography

• signs and symptoms to look out for and seek advice on

• contact details for immediate referral to specialist care

• contact details for support services, for example, support for people with lymphoedema. [2009, amended 2023]

For medicines recommended as options in NICE technology appraisal guidance for treating triple negative, locally advanced breast cancer in some people, see the guidance on:

• talazoparib (TA952, 2024)

• sacituzumab govitecan (TA819, August 2022)

• pembrolizumab plus chemotherapy (paclitaxel or nab-paclitaxel) (TA801, June 2022)

• atezolizumab with nab-paclitaxel (TA639, 2020).

For medicines recommended as options in NICE technology appraisal guidance for treating HER2-positive, locally advanced breast cancer in some people, see the guidance on:

• tucatinib with trastuzumab and capecitabine (TA786, 2022)

• pertuzumab, in combination with trastuzumab and docetaxel (TA509, 2018)

• trastuzumab emtansine (TA458, 2017).

For medicines recommended as options in NICE technology appraisal guidance for treating hormone receptor-positive, HER2-negative, locally advanced breast cancer in some people, see the guidance on:

• talazoparib (TA952, 2024)

• palbociclib with fulvestrant (TA836, October 2022)

• alpelisib plus fulvestrant (TA816, August 2022)

• abemaciclib with fulvestrant (TA725, September 2021)

• ribociclib with fulvestrant (TA687, March 2021)

• abemaciclib with an aromatase inhibitor (TA563, 2019)

• ribociclib with an aromatase inhibitor (TA496, December 2017)

• palbociclib with an aromatase inhibitor (TA495, December 2017)

• everolimus with exemestane (TA421, 2016).

For medicines not recommended in NICE technology appraisal guidance for treating locally advanced breast cancer in some people, see the guidance on:

• eribulin (TA515, March 2018)

• fulvestrant (TA503, January 2018) for untreated oestrogen-receptor-positive breast cancer

• fulvestrant (TA239, 2011) for oestrogen-receptor-positive breast cancer that has relapsed or progressed on or after anti-oestrogen therapy.