Red Flags
- New breast lump, skin tethering, peau d'orange, nipple retraction or discharge, axillary lymphadenopathy — same-day imaging and triple assessment[1]
- Inflammatory breast cancer (rapid skin changes, oedema, erythema, peau d'orange) — emergent multidisciplinary oncology; neoadjuvant chemotherapy[1]
- BRCA1/2 or other high-penetrance mutation in patient or strong family history — clinical genetics; consider risk-reducing surgery and intensified surveillance[1]
- Pregnancy with newly diagnosed breast cancer — multidisciplinary oncology + obstetric; staging-appropriate chemotherapy from second trimester possible[1]
First-line treatment
Interventions
- Multidisciplinary tumour board for all[1]Surgical, medical, and radiation oncology + radiology + pathology; treatment driven by stage and molecular subtype (luminal A/B, HER2-positive, triple-negative)
- Surgery — BCS or mastectomy[1]Breast-conserving surgery with whole-breast radiotherapy is equivalent to mastectomy for early-stage in survival; mastectomy for large tumour:breast ratio, multicentric disease, or contraindication to RT; sentinel lymph node biopsy for clinically node-negative
- Adjuvant radiotherapy[1]Whole-breast RT after BCS; post-mastectomy RT for ≥4 positive nodes, T3+, or close margins; nodal RT per axillary status
- Genomic risk-stratification (Oncotype DX, MammaPrint)[1]ER-positive HER2-negative N0 disease — informs decision on adjuvant chemotherapy where benefit uncertain; access varies by setting
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Tamoxifen[1] | Selective estrogen receptor modulator | 20 mg PO daily × 5–10 years | — | Adjuvant for premenopausal ER-positive; risk of VTE and endometrial cancer — counsel about postmenopausal bleeding; CYP2D6 interactions (avoid SSRIs that inhibit CYP2D6 like paroxetine, fluoxetine) |
| Aromatase inhibitor (anastrozole, letrozole, exemestane)[1] | Aromatase inhibitor | Anastrozole 1 mg PO daily; letrozole 2.5 mg PO daily; exemestane 25 mg PO daily — × 5–10 years | — | Adjuvant for postmenopausal ER-positive; switch from tamoxifen at menopause; bone loss — DXA and calcium/vitamin D ± bisphosphonate; arthralgia |
| Trastuzumab[1] | Anti-HER2 monoclonal antibody | Loading 8 mg/kg IV then 6 mg/kg every 3 weeks × 1 year; or weekly schedule | — | All HER2-positive (IHC 3+ or FISH amplified); cardiotoxicity — baseline and serial echocardiogram; combine with chemotherapy then continue alone |
| Pertuzumab + trastuzumab + chemotherapy | Dual HER2 blockade | Pertuzumab 840 mg loading then 420 mg IV every 3 weeks | — | The July 2020 ICMR breast-cancer STW lists pertuzumab among HER2-directed options for metastatic breast cancer; this source does not establish the current neoadjuvant/adjuvant indication. [2] |
| CDK4/6 inhibitor (palbociclib, ribociclib, abemaciclib) | Cyclin-dependent kinase inhibitor | Palbociclib 125 mg PO daily 21/28; ribociclib 600 mg PO daily 21/28; abemaciclib 150 mg PO BD continuous | — | The July 2020 ICMR breast-cancer STW lists CDK4/6 inhibitors among hormonal-treatment options for metastatic breast cancer; it does not state a high-risk early-stage indication. [2] |
| Neoadjuvant/adjuvant taxane + anthracycline chemotherapy[1] | Combination chemotherapy | AC-T or TC regimens per local protocol; dose-dense or weekly paclitaxel options | — | Standard for triple-negative, high-risk ER-positive, HER2-positive (with trastuzumab); cardiotoxicity, neuropathy, alopecia, neutropenia |
| PARP inhibitor (olaparib, talazoparib)[1] | Poly ADP-ribose polymerase inhibitor | Olaparib 300 mg PO BD; talazoparib 1 mg PO daily | — | BRCA-mutated metastatic and selected adjuvant high-risk early-stage; counselling for genetic testing; haematological monitoring |
Tamoxifen[1]
Selective estrogen receptor modulator
- Adult
- 20 mg PO daily × 5–10 years
- Paediatric
- —
Adjuvant for premenopausal ER-positive; risk of VTE and endometrial cancer — counsel about postmenopausal bleeding; CYP2D6 interactions (avoid SSRIs that inhibit CYP2D6 like paroxetine, fluoxetine)
Aromatase inhibitor (anastrozole, letrozole, exemestane)[1]
Aromatase inhibitor
- Adult
- Anastrozole 1 mg PO daily; letrozole 2.5 mg PO daily; exemestane 25 mg PO daily — × 5–10 years
- Paediatric
- —
Adjuvant for postmenopausal ER-positive; switch from tamoxifen at menopause; bone loss — DXA and calcium/vitamin D ± bisphosphonate; arthralgia
Trastuzumab[1]
Anti-HER2 monoclonal antibody
- Adult
- Loading 8 mg/kg IV then 6 mg/kg every 3 weeks × 1 year; or weekly schedule
- Paediatric
- —
All HER2-positive (IHC 3+ or FISH amplified); cardiotoxicity — baseline and serial echocardiogram; combine with chemotherapy then continue alone
Pertuzumab + trastuzumab + chemotherapy
Dual HER2 blockade
- Adult
- Pertuzumab 840 mg loading then 420 mg IV every 3 weeks
- Paediatric
- —
The July 2020 ICMR breast-cancer STW lists pertuzumab among HER2-directed options for metastatic breast cancer; this source does not establish the current neoadjuvant/adjuvant indication. [2]
CDK4/6 inhibitor (palbociclib, ribociclib, abemaciclib)
Cyclin-dependent kinase inhibitor
- Adult
- Palbociclib 125 mg PO daily 21/28; ribociclib 600 mg PO daily 21/28; abemaciclib 150 mg PO BD continuous
- Paediatric
- —
The July 2020 ICMR breast-cancer STW lists CDK4/6 inhibitors among hormonal-treatment options for metastatic breast cancer; it does not state a high-risk early-stage indication. [2]
Neoadjuvant/adjuvant taxane + anthracycline chemotherapy[1]
Combination chemotherapy
- Adult
- AC-T or TC regimens per local protocol; dose-dense or weekly paclitaxel options
- Paediatric
- —
Standard for triple-negative, high-risk ER-positive, HER2-positive (with trastuzumab); cardiotoxicity, neuropathy, alopecia, neutropenia
PARP inhibitor (olaparib, talazoparib)[1]
Poly ADP-ribose polymerase inhibitor
- Adult
- Olaparib 300 mg PO BD; talazoparib 1 mg PO daily
- Paediatric
- —
BRCA-mutated metastatic and selected adjuvant high-risk early-stage; counselling for genetic testing; haematological monitoring
Safety-net
- Be breast-aware: know what is normal for you and report any new lump, nipple change, skin change, or unexplained pain[1]
- Attend recommended mammography appointments — most early breast cancers are detected on screening before symptoms appear[1]
- Adjuvant therapy can last 5–10 years — adherence is the single biggest determinant of long-term survival; speak to your oncology team about side effects rather than stopping[1]
Referral criteria
- Suspicious clinical lesion, abnormal mammogram, or biopsy-proven cancerBreast cancer multidisciplinary clinic[1]
- Inflammatory breast cancer or rapidly progressive diseaseTertiary breast oncology same-week[1]
- BRCA1/2 mutation or strong family historyClinical genetics; consider risk-reducing mastectomy and salpingo-oophorectomy[1]
- Pregnancy with newly diagnosed breast cancerJoint oncology and obstetric clinic; staging-appropriate management[1]
Clinical summary
Risk-stratified screening, triple-assessment diagnosis, and stage- and subtype-driven treatment of breast cancer in adult women.