Breast cancer pathway

Invasive Ductal Carcinoma (IDC)

Cancer has spread outside of the ducts (tubes that carry milk to the nipple) to the surrounding breast tissue.

Ductal Carcinoma in Situ (DCIS)

Early form of breast cancer.

Secondary/Metastatic Breast Cancer

Cancer has spread from the first cancer (primary) to other parts of the body through the lymphatic or blood system.

Breast cancer in men

Cancer has formed in the breast tissue.

What to expect

This information describes the care you can expect from an initial concern about breast cancer and for every step afterwards
– your cancer pathway.

Needing immediate support

Breast Cancer Now helpline 0808 800 6000

Macmillan support line 0808 808 0000 (8am-8pm, 7 days a week)

Directory of Services

COVID-19 update

Please note that aspects of the cancer pathway may have changed due to the COVID-19 pandemic and these changes are highlighted throughout the pathway. If you have any concerns or questions, always speak to your GP or cancer care team.

The aim of the COVID-19 guidance is to:

  • minimise your risk by reducing investigation and visits to hospital
  • reassure you if you have low risk symptoms that you will be investigated within a safe time frame in line with national guidance
  • identify if you are at a higher risk and make sure you are investigated quickly and receive urgent surgery if required.

People you could meet on your pathway

Initial investigation and referral

Being breast aware is knowing what your breasts look like and how they feel.

  • The first noticeable symptom of breast cancer may be / is often a lump in the breast, a new inversion of the nipple or tethering of the skin of the breast.
  • It is important to be breast aware so you can pick up any changes as soon as possible.
  • Most breast lumps (90%) are not cancerous but it’s always best to have them checked by your doctor.
  • Get to know what is normal for you – for instance, your breasts may look or feel different at different times of your life. This will make it much easier to spot potential problems.

Symptoms of breast cancer include:

  • a new lump in either breast that was not there before
  • a change in the size or shape of one or both breasts
  • bloodstained discharge from your nipple
  • a lump or swelling in either of your armpits
  • dimpling on the skin of your breasts
  • a rash on or around your nipple
  • a change in the appearance of your nipple, such as becoming sunken into your breast.

If you have any of these symptoms, you should see a GP.

For more information about the signs and symptoms of breast cancer
Breast Cancer Now

COVID-19 update

If you have symptoms that you are worried may be cancer, it is important to still seek advice from your GP surgery. Your symptoms do not mean you have cancer and could be caused by a number of common conditions but it is always best to get checked.

Information about reporting symptoms of breast cancer during the COVID-19 pandemic

Breast Screening

The aim of breast screening is to detect a breast cancer early. You will be invited to attend for a mammogram every three years from the age of 50 to 71 as part of a national breast screening programme. A mammogram is an x-ray test that can spot cancers when they’re too small to see or feel.

If you are 71 or over, a breast screening invitation will not automatically be sent, however, you can ask to continue breast screening every three years. Your GP can put you in touch with your local screening unit or you can look them up.

Some breast screening clinics in England are taking part in an age extension trial where some women under 50 and over 70 are invited to attend screening. This is to find out whether it is beneficial to extend the age range for breast screening.

For further information about breast screening, what happens, the results, and benefits and risks
Breast Cancer Now
NHS
Gov.uk

COVID-19 update

Breast screening services are now available again, however appointment slots are reduced to ensure safety between each patient. Appointment slots will gradually start to increase.

You will be invited for breast screening programme from the age of 50 to 71 (until your 71st birthday). This means you will receive an invitation by your 53rd birthday.

Until further notice there will no longer be a facility for women over the age of 71 to self-refer to the screening programme. If you are over the age of 71 and have any breast concerns, your GP will be able to refer you using a fast track referral as usual.

For more information about fast track referrals during the COVID-19 pandemic download a fast track referrals leaflet:

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Due to the ongoing pandemic, the age extension trial (screening from the age 47 to 50 and 70 to 73) has been stopped until further notice.

If you are unable to attend your screening appointment, currently you will not be offered a another.

More information about screening during COVID-19

How should you check your breasts?

There’s no right or wrong way to check your breasts but it is important to know how your breasts usually look and feel. That way, you can spot any changes quickly and report them to your GP.

Every woman’s breasts are different in terms of size, shape and consistency. It’s also possible for one breast to be larger than the other.

Get used to how your breasts feel at different times of the month. Your breasts can change during your menstrual cycle. For example, you may have tender and lumpy breasts, especially near the armpit, around the time of your period.

For information on the signs and symptoms of breast cancer
Breast Cancer Now

Your GP will assess any symptoms you may notice, examine both of your breasts and possibly arrange blood tests.

After examining you, your GP may:

  • feel there is no need for further investigation and reassure you
  • ask you to make another appointment with them in a short amount of time for review and another examination
  • refer you to a breast clinic using a fast track referral
  • your GP may also refer you using a fast track referral for breast symptoms even if they do not necessarily suspect these are due to cancer. This is called a symptomatic breast fast track referral where the GP feels the input of a consultant is needed.

COVID-19 update

During the COVID-19 pandemic fast track referrals are still essential but they may be managed differently.

For more information about fast track referrals during the COVID-19 pandemic download a fast track referrals leaflet:

English

Easy Read

العربية (Arabic)

বাংলা (Bengali)

فارسی (Farsi)

کوردی (Kurdish)

Polski

Tagalog

Even if you are referred to a breast clinic, this does not necessarily mean you have breast cancer. Non-cancerous breast conditions are very common and a referral is made for all breast problems, not just a suspected cancer.

For more information on benign breast conditions
Breast Cancer Now

Suspected cancer

You will be invited to attend a breast clinic at the hospital if you have been referred by your GP or if you have been recalled following a routine screening appointment. It is okay to feel anxious or worried about this.

Many people seen in a breast clinic will not have breast cancer but it is important to attend so you can be fully assessed.

At your appointment you will usually have a breast examination, following this you may have one or more of the below tests.

Mammogram

A mammogram is an X-ray test that can spot cancers when they’re too small to see or feel.

Ultrasound scan

This is a procedure which uses high-frequency sound waves to create a detailed image of part of the inside of the body.

Breast core biopsy

This type of breast biopsy is a procedure to remove a small sample of breast tissue to test and determine whether it is a breast cancer.

Fine needle aspiration (FNA)

This is a way of taking a sample of cells from the breast tissue using a fine needle and syringe. The cells are examined under a microscope.

When you come for your breast clinic, all your tests may be performed in a ‘one-stop’ clinic where they are all carried out during one visit to clinic. But it is not always possible to complete all the tests in one appointment.

The time it takes for your appointment may vary depending on which tests you need; it can take several hours if you need to have all the tests done.

Please check with your hospital whether you can bring a friend or family member with you to your appointment.

Breast cancer terminology and glossary
Breast Cancer Now

Coming back for your results

Some of the results for the tests may be available later the same day however, if you have a biopsy this will take longer. You may have to wait two to three weeks for your biopsy results. You might receive your results by letter or you will be asked to attend the clinic for them.

Diagnosis

If you are diagnosed with breast cancer you will receive an appointment with your consultant to discuss your diagnosis and treatment recommendations. You are welcome to bring a family member or a friend with you to this appointment.

Depending on what your consultant recommends for your specific breast cancer, you will discuss your treatment options.

Treatment

The best course of treatment for you will be discussed within a team of specialists called a multidisciplinary team (MDT).

Multidisciplinary team

A multidisciplinary team (MDT) is a group of health care professionals who are from one or more clinical disciplines who make decisions together regarding the recommended treatment for individual patients. 

COVID-19 update

Your treatment may be affected by the pandemic and your cancer care team will provide you with information on this. If you have any concerns or questions, please contact your hospital.

It is understandable that you may be worried about going into hospital where patients with COVID-19 are being cared for but please be reassured your safety is a priority. Hospital areas are kept separate and carefully managed for your safety.

Treatment options will be discussed with you and a treatment plan will be prepared.  Parts of this plan could change as more information about the cancer in your breast becomes available. For example, the results of tests performed on the breast tissue removed during an operation.

For more information about understanding test results
Breast Cancer Now

You may want to take a list of questions to ask during discussions.

You may also ask for a second opinion or decline treatment completely.

Treatments for primary breast cancer

The treatment you have will depend on the type of breast cancer you have. Your consultant will discuss the treatment recommendations with you and develop a treatment plan.

You may have one or a combination of treatments below.

 

Surgery

COVID-19 update

Prior to surgery you should socially distance and you will be tested for COVID-19 before your operation, following your swab you should self-isolate. Information on how to do this properly will be provided by your cancer care team. If you have any signs or symptoms of COVID-19, your operation will be postponed until you have recovered.

Surgery is usually the first treatment for most people with breast cancer. The aim of surgery is to remove the cancer from the breast and the lymph nodes under the arm.

There are two main types of surgery


Breast conserving surgery

This is also known as a wide local excision (WLE). This surgery removes the cancer with a margin of normal, healthy breast tissue. The aim is to make sure all the cancer has been removed whilst keeping as much of the breast as possible.

The removed breast tissue will be carefully examined to check the margins are clear of cancer cells. If there are still cancer cells present at the edges of the margin, further surgery may need to be carried out to remove more tissue. Some people may require a mastectomy.

For more information about breast conserving surgery
Macmillan Cancer Support

Mastectomy

A mastectomy is the removal of all the breast tissue, including the skin and the nipple area.

Mastectomy may be recommended if the cancer takes up a large area of the breast or when there is more than one area of cancer within the breast. Your surgeon will discuss why a mastectomy is recommended.  You may still want to have a mastectomy even if breast-conserving surgery is an option.

Breast reconstruction after a mastectomy can be considered. Your surgeon will discuss with you whether a reconstruction is appropriate for you and, if so, whether it is advisable to have this at the time of mastectomy (immediate reconstruction) or at a later date when you have completed your cancer treatment (delayed reconstruction).

There are several types of reconstruction. Your surgeon will discuss these with you and advise which options are suitable for you. You may be referred to a different hospital for some types of reconstruction.

For more information about mastectomy
Macmillan Cancer Support

Other types of surgery

Lymph node surgery

If you have an invasive breast cancer, it will be necessary to check if any of the lymph nodes under your arm contain cancer cells. This information helps the consultants decide what other types of treatment to recommend for you. To help decide what type of lymph node surgery is required, you will have an ultrasound of your armpit and possibly a biopsy.

For more information about lymph node surgery
Breast Cancer Now

Sentinel lymph node biopsy

You would have this operation if tests before your surgery show no evidence of the lymph nodes containing cancer cells. The sentinel lymph nodes, the first lymph nodes the cancer cells are most likely to spread to, are identified and removed, and sent for examination. In most cases the sentinel nodes are confirmed to be clear of cancer.

However, if the sentinel nodes contain cancer cells, further surgery to the lymph nodes (axillary node clearance) may be recommended.

For more information about sentinel lymph node biopsy
Breast Cancer Now

Axillary Node Clearance

This is the removal of all the lymph nodes from the axilla (armpit). This is normally recommended if the lymph nodes are found to contain cancer either on ultrasound and biopsy before surgery or following sentinel node biopsy.

Chemotherapy

This is the use of anti-cancer drugs to destroy cancer cells and reduce the risk of the cancer returning.  Many types of chemotherapy drugs are used to treat breast cancer and these can be given in different ways and combinations.

Your cancer care team will discuss with you whether chemotherapy is recommended. This recommendation will be based on specific details of your tumour including the tumour size, whether the lymph nodes are affected, the grade of your cancer and other factors.

If chemotherapy is required, it is usually given after surgery and before radiotherapy. This is called adjuvant chemotherapy.

Chemotherapy is sometimes given before surgery. This is recommended for certain types of breast cancer or to shrink a larger breast cancer before surgery. This is called primary or neoadjuvant chemotherapy.

Chemotherapy drugs are mainly given through a vein, but some can be taken by mouth as tablets or capsules.

Side effects of chemotherapy include:

  • infections
  • loss of appetite
  • feeling sick
  • being sick
  • tiredness
  • hair loss
  • sore mouth
  • neutropenia (loss of white blood cells which fight infection).

If you are feeling unwell during chemotherapy, please contact your chemotherapy hotline. Your cancer care team will give you information about the hotline before you start treatment.

For more information on chemotherapy and the types of chemotherapy drugs you may have for breast cancer
Breast Cancer Now

Radiotherapy

Radiotherapy is the use of carefully measured and controlled high energy x-rays to destroy any cancer cells left behind in the breast and the surrounding area after surgery.

Radiotherapy will usually be given following surgery. If you are having chemotherapy after your surgery, radiotherapy is usually given after you have finished chemotherapy.

For more information about breast radiotherapy
Breast Cancer Now

Hormone therapy

Hormone therapy (also known as endocrine therapy) works to block or stop the effect of oestrogen on cancer cells which can cause them to grow.

If your tumour has receptors for oestrogen (referred to as hormone receptor positive), hormone therapy will most likely be recommended. This is usually in the form of tablets. Your cancer care team will discuss this with you and which hormone therapy treatment is most appropriate. Hormone therapy is normally taken for at least five years.

Some of the types of hormone therapy are:

  • Tamoxifen
  • Anastrozole
  • Letrozole
  • Exemestane
  • Goserelin

The type you have will depend on different factors, for example if you have been through the menopause or not.

Hormone therapy is taken for several years and will usually be started after surgery or after chemotherapy if you are having it (adjuvant hormone therapy). You can take hormone therapy while you are having radiotherapy and your doctor will discuss this with you.

Hormone therapy can also be given as a primary treatment or sometimes prior to surgery to downstage the cancer.

For more information about hormone therapy
Macmillan Cancer Support

Targeted therapy

Breast cancer targeted therapy uses drugs to block the growth of breast cancer cells in specific ways. An example of a targeted therapy is Herceptin (Trastuzumab) which blocks the action of an abnormal protein (HER2) that stimulates the growth of breast cancer cells. Herceptin is used to treat tumours which are HER2 receptor positive. 

This type of treatment interferes with the way in which cancer cells grow. It reduces the risk of breast cancer returning in people who are HER2 positive.

Types of targeted therapy:

  • Trastuzumab – the main targeted therapy drug used
  • Pertuzumab – may be used in combination with Trastuzumab.

For more information on targeted therapies
Breast Cancer Now

Bisphosphonates

These are drugs and are given (usually to postmenopausal women) to reduce the risk of breast cancer returning in the bones. Bisphosphonates can also be used to protect the bones from the side effects of treatments such as hormone therapy.

For more information on bisphosphonates
Macmillan Cancer Support

Clinical trials

Clinical trials are important to develop and test new treatments including surgery, radiotherapy, chemotherapy and hormone therapy. Most breast cancer clinical trials were suspended during COVID but are now running again, your cancer care team will discuss with you if you are eligible for a trial.

After treatment

You will have regular check-ups and your consultant to monitor your progress. You will have a care plan detailing your follow-up care based on the type of cancer and treatment you have had.

Your GP will be sent a treatment summary from the hospital. Follow up after treatment will depend on your individual needs and a follow-up plan will be created with your cancer care team. You will be offered regular mammograms depending on the type of surgery you had.

If you are under 50, you will be offered a yearly mammogram until you are invited to take part in the national breast screening programme. If you were already eligible for the breast screening programme, you will have a yearly mammogram for five years.

During your follow up period you can contact your clinical nurse specialist to discuss any concerns that you have between your appointments. You can also see your GP with any new concerns.

After you have been discharged from follow up, your GP will be your main contact for help with any concerns you may have. Make sure they are aware of your previous breast cancer diagnosis, especially if it has been a while since your diagnosis or you have changed GP. Your GP can refer you back to your cancer care team if needed.

COVID-19 update

Your end of treatment clinic may be via telephone rather than a face-to-face review to minimise hospital visits.

You should be offered a recovery package consisting of 4 main parts:

  • holistic needs assessment and care planning
  • treatment summary
  • a GP review
  • health and wellbeing support event.

COVID-19 update

Your end of treatment clinic may be via telephone rather than a face-to-face review to minimise hospital visits.

If breast cancer returns

Sometimes breast cancer can come back after treatment but everyone is different. It is also possible to develop a new breast cancer.

Breast cancer returning is known as a recurrence and there are several different types of recurrence which depend on where in the body the cancer has returned.

Local recurrence

If the breast cancer returns in the breast, chest wall or the lymph nodes in the armpit.

Regional recurrence

If the breast cancer returns and spreads to the tissues and lymph nodes around the chest, neck and under the breastbone.

Your cancer care team will inform you of the signs and symptoms to look out for so you can report these as soon as possible to your GP or clinical nurse specialist.

Changes to the breast or chest area:

  • swelling on your chest
  • discharge from the nipple without squeezing
  • changes in shape and/or size
  • swelling in the arm or hand
  • changes in skin texture, for example puckering or dimpling
  • redness or a rash
  • nipple inversion
  • a lump or skin thickening.

Please note, this is not an exhaustive list and you should report any symptom that you are concerned about.

COVID-19 update

It is important that if you have had a previous breast cancer diagnosis that you report any symptoms you have to either the breast care team or your GP to have these checked.

Secondary breast cancer

This is also called metastatic cancer. This is where breast cancer cells which have spread from the primary site of cancer in the breast grow to form tumours in other parts of the body.

Signs and symptoms that you must report to your GP or clinical nurse specialist:

  • shortness of breath
  • pain
  • weight loss
  • dizziness
  • headaches
  • visual disturbances
  • persistent nausea or vomiting
  • confusion/memory loss
  • back pain or changes in existing back pain
  • weakness, heaviness or stiffness in limbs
  • numbness or pins and needles in limbs
  • alteration, loss of sensation, loss of control of your bowel and/or bladder function.

There are many possible explanations for these symptoms but it is important to get checked by your GP or contact with your cancer care team.

For more information about secondary breast cancer
Breast Cancer Now

Living with and beyond cancer

Emotional impact

How you cope with your diagnosis and treatment will be specific to you. You may expect to feel relief once your hospital-based treatment ends but this is not always the case and it can be a difficult and emotional time.

Following treatment, you may have time to reflect on the impact of your diagnosis. It is completely normal to have a mixture of emotions if you are living with or affected by cancer. There are a lot of support services available to help you through. It is important to remember you are not alone.

You may benefit from:

  • talking to friends and family
  • communicating with others in the same situation
  • talking therapies and counselling
  • moving forward courses
  • local support groups
  • health and wellbeing events.

For more information about dealing with your feelings and emotions
Macmillan Cancer Support
Penny Brohn UK

Advice for carers, family members, friends and colleagues about supporting someone with cancer
Macmillan Cancer Support

To find out about different types of support, talk to your clinical nurse specialist or Breast Cancer Now on 0345 077 1893.

More information

Breast Cancer Now – Living with and beyond breast cancer

Cancer Research UK – Support at home for you and your family

Local support groups
Directory of Services

Online support – You can get support on the internet via online support groups, social networking sites, forums, chat rooms and blogs for people who are affected by cancer.

For information about counselling services
British Association of Counselling and Psychotherapy

If you are feeling depressed or need to speak to someone immediately, please contact Samaritans 116 123

If you are struggling with how you are feeling emotionally, it is important to speak to your GP or your cancer care team, they will be able to provide you information on the treatments and support available to you.

Changes to your appearance

Treatments for breast cancer can cause changes to your body. For example, you could be left with a scar or scars after surgery or you may have lost your hair through having chemotherapy. You may also put weight on during or after treatment.

These changes can be difficult to accept and addressing your concerns is important.

For more information on changes to your appearance
Breast Cancer Now

Maintaining a healthy lifestyle

Following your treatment, there are many things you can do that may help to reduce the risk of lung cancer recurrence and prevent other health conditions.

You can take care of yourself by:

  • Stopping smoking
    Your cancer care team and your GP can help as well as the national stopping-smoking service.
    NHS
    Livewell Dorset
  • Managing tiredness
    Your clinical nurse specialist can discuss this with you and perhaps how family and friends could support you with day to day tasks.
  • Getting more active
    SafeFit
  • Eating well and maintaining a healthy weight
    NHS
  • Sticking to sensible drinking guidelines
    Drinkaware
  • Reducing stress

For more information about taking care of yourself
Macmillan Cancer Support

For more information about lifestyle after treatment

Breast Cancer Now BECCA – the free breast cancer care app
Breast Cancer Now Moving Forward courses – a programme of information sessions to help you adjust and adapt after diagnosis.

Breast Cancer Now – Moving forward after breast cancer treatment

Breast Cancer Now – After breast cancer treatment: what now? or contact their helpline 0808 800 6000

Talking about cancer

It can be difficult to tell people you have cancer, however talking to your closest friends and family can make you feel more supported and reassured that the feelings you may be experiencing are normal. Everyone you tell may have a different reaction and it is important to be prepared for this. Some will be keen to support you but this may not always be the case as some people may find the conversation difficult and uncomfortable. This may be through lack of experience, fearing your reaction or they may go into denial.

View videos of people talking about their own experiences and coping with people’s reactions
healthtalk 

It can also help to talk to people who also have cancer as they may have a better understanding of what you are going through.

For more information on talking about cancer
Macmillan Cancer Support

Complementary therapies

Complementary therapies can be used alongside conventional breast cancer treatments. These are not the same as alternative therapies which are used instead of conventional treatments, such as chemotherapy or radiotherapy.

Complementary therapies can give you comfort and help you feel more relaxed after treatment and diagnosis. Types of complementary therapies can include:

  • activities that improve mindfulness
  • acupuncture
  • acupressure and shiatsu
  • aromatherapy
  • healing and energy therapies
  • herbal therapies
  • hypnotherapy
  • massage
  • meditation
  • mindfulness
  • reflexology
  • special ‘cancer diets’ and dietary supplements
  • yoga, Tai Chi and Chi Gung.

You can discuss what complementary therapies are available to you with your cancer care team.

For more information about complementary therapies
Macmillan Cancer Support

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