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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Breast cancer is not one disease, and the result that decides which page you need is the receptor result: whether the cancer carries oestrogen and progesterone receptors, and whether it carries too much HER2. Those two answers give four boxes, not three, with a page for each. Grade and stage do not change which page you read; they change what happens on it.
Breast cancer arises from the milk ducts or lobules and is classified by the receptors on its cells: oestrogen and progesterone receptors, and HER2. Hormone receptor-positive, HER2-negative disease is treated with endocrine therapy and CDK4/6 inhibitors; HER2-positive disease with HER2 antibodies and antibody-drug conjugates; triple-negative disease with chemotherapy, immunotherapy and, for BRCA carriers, PARP inhibitors. Ductal carcinoma in situ is a precursor confined to the duct, and about one percent of cases occur in men. Screening mammography from around age 50, breast-conserving surgery with radiotherapy, sentinel node biopsy and genomic tests that spare chemotherapy are common to all types. Most patients present early and are cured. Metastatic disease is treated in successive lines rather than once, is controlled for years in many people, and is rarely cured; the subtype pages carry the sequence, the trials open in each line and the point at which a trial is a reasonable choice beside standard treatment.
| Setting | Approach | Guideline |
|---|---|---|
| Early disease, all types | Breast-conserving surgery with radiotherapy or mastectomy, sentinel node biopsy, then treatment by receptor type on the subtype pages. | not mapped |
| Ductal carcinoma in situ | Surgery with or without radiotherapy and endocrine therapy; active surveillance under study. | not mapped |
| Every invasive breast cancer, at diagnosis | Oestrogen receptor, progesterone receptor and HER2 assessed simultaneously on the diagnostic biopsy by quality-assured immunohistochemistry, reported quantitatively, with reflex in situ hybridisation for a HER2 score of 2+, and the results available at both the preoperative and the postoperative multidisciplinary meeting. The pathology report also carries the histological type, the Nottingham grade with its three component scores, the invasive and whole tumour size, the node stage and the margins. | not mapped |
| Staging and prognostic assessment | Ultrasound of the axilla with needle sampling of any abnormal node before treatment; MRI only where the extent is unclear, the breast is too dense to assess or a lobular cancer is being sized for breast-conserving surgery. Stage against UICC TNM 8, and put grade, node stage and size together in the Nottingham Prognostic Index and in PREDICT, which estimates the benefit of each adjuvant treatment. In advanced disease, contrast-enhanced CT of chest, abdomen and pelvis or FDG PET-CT. | not mapped |
| At recurrence | Consider reassessing hormone receptor and HER2 status on a biopsy of the recurrence where a change in receptor status would change management, because conversion between the primary and a metastasis is common in both directions. | not mapped |
| Surgery to the breast: conservation or mastectomy | Breast-conserving surgery with radiotherapy, or mastectomy, depending on the size of the tumour against the size of the breast, whether there is more than one tumour, whether radiotherapy is possible, and what the woman wants. Survival is the same either way and has been for twenty years: NSABP B-06 found a hazard ratio for death of 0.97 (0.83 to 1.14) for lumpectomy with irradiation against mastectomy, Milan I found death from any cause of 41.7 against 41.2 percent at twenty years, and EORTC 10801 found a hazard ratio of 1.11 (0.94 to 1.33) at a median 22.1 years. What differs is recurrence in the conserved breast, which is why radiotherapy goes with conservation. Oncoplastic techniques widen the range of tumours that can be conserved. | not mapped |
| Margins and further surgery | Re-excision or mastectomy when tumour reaches the inked margin. NICE NG101 recommendation 1.4.3 offers further surgery when invasive cancer or ductal carcinoma in situ is present at the radial margin (0 mm), and recommendation 1.4.5, new in 2024, considers it when tumour cells lie within 1 mm of but not at the radial margin. The threshold for invasive cancer was lowered from 2 mm to 1 mm because the evidence could not separate 1 to 2 mm from more than 2 mm on local recurrence, and repeated operations harm appearance and self-image. For ductal carcinoma in situ alone the 2 mm threshold is retained (recommendation 1.4.4). | not mapped |
| Staging the axilla when the nodes look clear | Sentinel lymph node biopsy, not axillary clearance, with dual technique using isotope and blue dye (NICE NG101 recommendations 1.4.9 and 1.4.10). NSABP B-32 randomised 5,611 women and found eight-year overall survival of 90.3 percent with sentinel node biopsy alone against 91.8 percent with added clearance (hazard ratio 1.20, 0.96 to 1.50); ALMANAC measured the gain, with lymphoedema at one year falling from 13 to 5 percent and sensory loss from 31 to 11 percent. In selected patients the sentinel node itself can now be omitted: SOUND (tumours up to 2 cm, clear axillary ultrasound) and INSEMA (T1 and T2, breast-conserving surgery) both showed non-inferiority, with axillary recurrence in INSEMA of 1.0 against 0.3 percent. Omission is only reasonable where the missing nodal information would not change the treatment plan. | not mapped |