The National Institute for Health and Clinical Excellence (NICE) has issued clinical guidelines for the diagnosis and treatment of advanced breast cancer.

This guideline updates and replaces NICE technology appraisal guidance 62 for capecitabine, 54 for vinorelbine, and 30 for taxanes.

In terms of medical management, NICE makes the following recommendations (taken directly from source):

• Offer endocrine therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer.
• Offer chemotherapy as first-line treatment for patients with ER-positive advanced breast cancer whose disease is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement, providing they understand and are prepared to accept the toxicity.
• For patients with ER-positive advanced breast cancer who have been treated with chemotherapy as their first-line treatment, offer endocrine therapy following the completion of chemotherapy.

With respect to endocrine therapy:
• Offer an aromatase inhibitor (either non-steroidal or steroidal) to postmenopausal women with ER-positive breast cancer and no prior history of endocrine therapy or postmenopausal women with ER-positive breast cancer previously treated with tamoxifen.
• Offer tamoxifen and ovarian suppression as first-line treatment to premenopausal and perimenopausal women with ER-positive advanced breast cancer not previously treated with tamoxifen.
• Offer ovarian suppression to premenopausal and perimenopausal women who have previously been treated with tamoxifen and then experience disease progression.
• Offer tamoxifen as first-line treatment to men with ER-positive advanced breast cancer.

With respect to chemotherapy:
• On disease progression, offer systemic sequential therapy to the majority of patients with advanced breast cancer who have decided to be treated with chemotherapy.
• Consider using combination chemotherapy to treat patients with advanced breast cancer for whom a greater probability of response is important and who understand and are likely to tolerate the additional toxicity.
• For patients with advanced breast cancer who are not suitable for anthracyclines (because they are contraindicated or because of prior anthracycline treatment either in the adjuvant or metastatic setting), systemic chemotherapy should be offered in the following sequence:
 first line: single-agent docetaxel
 second line: single-agent vinorelbine or capecitabine
 third line: single-agent capecitabine or vinorelbine (whichever was not used as second-line treatment).
• Gemcitabine in combination with paclitaxel, within its licensed indication, is recommended as an option for the treatment of metastatic breast cancer only when docetaxel monotherapy or docetaxel plus capecitabine are also considered appropriate.

Finally, for patients who are receiving treatment with trastuzumab for advanced breast cancer, discontinue treatment with trastuzumab at the time of disease progression outside the central nervous system. Do not discontinue trastuzumab if disease progression is within the central nervous system alone.

The guideline also discusses the management of complications of lymphoedema, cancer-related fatigue, uncontrolled local disease, bone metastases, and brain metastases.