Younger or premenopausal women

Bone mineral density assessment

Consider imaging with dual energy x-ray (DEXA) to measure bone mineral density in patients with breast cancer treated with chemotherapy and/or endocrine therapy. 

Psychosocial assessment – High risk

A detailed psychosocial assessment should be undertaken for patients at a higher risk of depression, e.g. patients with a history of mental health issues, patients with caring responsibilities, patients under financial stress, young patients, and those with multiple stressors.

Imaging after breast-conserving surgery – Young patients with high-risk gene mutation

In patients less than 50 years of age who are carriers of high-risk gene mutations (e.g. BRCA1/2) and who have not undergone risk-reducing mastectomy, consider the use of annual magnetic resonance imaging (MRI) of both breasts during follow-up.

Radiation therapy boost after breast-conserving surgery

In patients who have undergone breast-conserving surgery and who are at high risk of local recurrence (age ≤50 years with any grade, age 51-70 years with higher grade, or a positive margin), offer radiation therapy boost following whole-breast radiation therapy.

BCS or mastectomy – Patients with gene mutation

In patients with breast cancer with a confirmed germline mutation (e.g. BRCA1/2), that predisposes to an increased risk of breast cancer discuss the options of breast-conserving surgery, mastectomy or bilateral mastectomy, noting that there is a higher risk of a second malignancy if the breast is conserved, but that this risk is reduced by adjuvant systemic therapy.

Genetic risk assessment

All patients with breast cancer should be assessed at or around the time of diagnosis for familial and genetic risk factors as indicated in current eviQ guidelines, which include relevant pathogenic variants in adult blood relatives, gender, ancestry, breast cancer characteristics, and personal and family cancer history.

Adjuvant chemotherapy – Combination with endocrine therapy

Chemotherapy can be given concurrently with the gonadotropin-releasing hormone (GnRH) agonist goserelin but not with tamoxifen.

Genetic counselling and testing – Referral

In accordance with eviQ guidelines, patients suspected of having high familial or genetic cancer risk should be referred to a family cancer clinic for genetic counselling and genetic testing as appropriate.

Fertility considerations – Referral

Discuss fertility issues and the implications of premature menopause with all premenopausal women. Arrange early referral to a fertility specialist to maximise the opportunity for consideration of fertility preservation if appropriate and feasible.

Endocrine therapy and bone health – Advice to patients

Advise patients on the importance of weight-bearing exercise and on adequate calcium intake and vitamin D levels.

Initial adjuvant endocrine therapy – Men and premenopausal women

Offer tamoxifen as the initial adjuvant endocrine therapy for men and premenopausal women with ER-positive invasive breast cancer with low risk of recurrence.

Pregnancy considerations

Premenopausal women should be counselled regarding the risk of becoming pregnant while on chemotherapy, endocrine therapy, anti-HER2 therapy, or during radiation therapy, even in the presence of amenorrhoea.

Contraception considerations #1

Discuss and offer barrier contraceptive options (condoms or diaphragms, a copper intrauterine device, or surgical options) for premenopausal women with breast cancer, noting that systemic hormonal contraception is contraindicated irrespective of disease subtype.

Ovarian function suppression – Use of GnRH agonist #1

For premenopausal women with ER-positive breast cancer at higher risk of recurrence, consider ovarian function suppression with a gonadotrophin releasing hormone (GnRH) agonist in addition to endocrine therapy (tamoxifen or aromatase inhibitors), noting that a GnRH agonist must be used with aromatase inhibitors. 

Systemic therapy planning considerations – Premenopausal women

Offer temporary ovarian suppression with a gonadotrophin releasing hormone (GnRH) agonist such as goserelin during chemotherapy to all premenopausal breast cancer patients undergoing chemotherapy who are interested in preventing early menopause and/or preserving fertility. Commence goserelin at least one week prior to the commencement of chemotherapy.

Ovarian function suppression – Use of GnRH agonist #2

If a gonadotropin-releasing hormone (GnRH) agonist is used in premenopausal women, it should be given on a monthly basis to optimise ovarian suppression. 

Contraception considerations #2

Premenopausal women should be advised not to use a levonorgestrel-releasing intra-uterine device (LNG-IUD) and to use alternative non-hormonal contraception, as the safety of the LNG-IUD among women with breast cancer has not been determined.

Adjuvant bisphosphonate treatment – Premenopausal women

Consider the use of zoledronic acid as adjuvant therapy for premenopausal women receiving ovarian suppression. 

Endocrine therapy with tamoxifen – Duration of therapy

Consider extending the duration of tamoxifen therapy beyond 5 years for premenopausal or postmenopausal women with ER-positive breast cancer.

Risk-reducing strategies #2

In premenopausal women with breast cancer with a confirmed germline mutation (e.g. BRCA 1/2) that predisposes to an increased risk of breast cancer, discuss risk-reducing strategies (e.g. contralateral risk-reducing mastectomy or endocrine therapy/ risk-reducing medication).

Risk-reducing strategies #3

In women with breast cancer with a confirmed germline mutation (e.g. BRCA 1/2) that predisposes to an increased risk of ovarian/fallopian tube cancer, refer to a gynaecological oncologist for discussion of the benefits and risks of bilateral salpingo-oophorectomy (BSO).

MDT treatment planning – Pregnant women

Include obstetricians and perinatologists in the multidisciplinary team (MDT) for the treatment of patients with breast cancer during pregnancy. Particular attention should be paid to each woman’s preferences and psychosocial needs due to the higher likelihood of distress.

Infertility after treatment – Specialist referral

Patients of childbearing age who experience infertility after treatment for breast cancer should be referred to a specialist in reproductive endocrinology and infertility as soon as possible.