Treatment for early or locally advanced breast cancer aims to remove the cancer and reduce the risk of the cancer spreading or coming back ( recurring). As there are different types of breast cancer, treatment varies from person to person. Your doctors will recommend the most suitable treatment for you.
The choice of treatment will depend on your test results, where the cancer is in the breast, the cancer's stage and grade , and whether the cancer is hormone receptor or HER2 positive or triple negative, along with your age and general health, and your preferences. Usually more than one treatment is used, and treatments may be given in different sequences and combinations.
Men diagnosed with early or locally advanced breast cancer have similar treatment options to women. Some men may struggle with feelings of isolation or embarrassment, as breast cancer is most commonly diagnosed in women. Resources for men with breast cancer are available at Cancer Australia's Breast Cancer in Men.
Treatments for early or locally advanced breast cancer
If you have been diagnosed with early or locally advanced breast cancer, you will usually be offered surgery to remove the cancer. In some cases of locally advanced breast cancer, treatment begins with chemotherapy to shrink the tumour before surgery.
Surgery for early breast cancer will be either breast-conserving surgery, where part of the breast is removed, or a mastectomy, where the whole breast is removed. A mastectomy is usually recommended for locally advanced breast cancer.
In most cases, breast surgery also involves removing one or more lymph nodes from the armpit. In some cases, breast reconstruction will be done at the same time as a mastectomy, but it may also be done as a separate operation later.
Which surgery should I have?
Some women will be offered a choice between breastconserving surgery and a mastectomy. Men don't usually have breast-conserving surgery.
Research has shown that breast-conserving surgery, when combined with sentinel node biopsy and followed by radiation therapy, is as effective as mastectomy for most women with early breast cancer. The chance of the cancer coming back in another part of the body is the same with either type of surgery.
The operations have different benefits, risks and side effects. Talk to your doctor about the best option for you.
Types of surgery
How your breasts look after surgery will depend on the type of surgery and a range of individual factors. Your surgeon can show you more examples to help you choose the surgery that is right for you.
Two years after surgery to left breast. The surgery was followed by radiation therapy.
Left breast removed, with no reconstruction.
Nipple-sparing mastectomy with implant reconstruction
Right breast removed with a nipple-sparing mastectomy, followed by reconstruction using an implant. If it is not possible to keep the nipple, there is the option of having a nipple reconstruction later.
Mastectomy with a flap reconstruction
Right breast removed, followed by reconstruction using tissue from the back. A reconstruction can also be done with tissue from the abdomen, buttock or thigh. Some women choose to have a nipple reconstruction later.
Surgery to remove the breast cancer and some surrounding healthy tissue is called breast-conserving surgery. It is also called a lumpectomy or wide local excision. Breast-conserving surgery is recommended if the cancer is relatively small compared to the size of your breast. The surgeon removes the tumour and a rim of breast tissue, while leaving as much breast tissue as possible. This will leave a scar and may change the size and shape of the breast and the position of the nipple.
The removed tissue is sent to a laboratory. A specialist called a pathologist checks it under a microscope to see if there is an area of healthy cells around the cancer - this is known as a clear margin. The pathologist will create a report, which will include information about:
The report will help guide further treatment. If cancer cells are found at the edge of the removed tissue (an involved or positive margin), there is a greater chance of the cancer returning. You may need more tissue removed (re-excision or wider excision), or your doctor may recommend a mastectomy (see below).
After breast-conserving surgery, most women have radiation therapy to the whole breast to destroy any undetected cancer cells that may be left in the breast or armpit, and to keep the cancer from coming back.
Oncoplastic breast-conserving surgery combines oncological surgery (to remove the cancer) with plastic surgery (to reshape the breast and try to preserve its appearance). It is performed by oncoplastic breast surgeons.
Occasionally, radiation therapy may not be required. Some women also need chemotherapy, targeted therapy or hormone therapy.
Surgery to remove the whole breast is called a mastectomy. You may be offered a mastectomy if:
- there is cancer in more than one area of the breast
- the cancer is large compared to the size of the breast
- you have had radiation therapy to the same breast before and so cannot have it again
- clear margins cannot be obtained
- you find out that you have the BRCA1 or BRCA2 gene mutation at the time of your breast cancer diagnosis.
You may decide that you would prefer a mastectomy rather than breast-conserving surgery, especially if you can't have radiation therapy. Some women choose a mastectomy even for a very small cancer.
Most mastectomies remove the nipple with the breast. In some cases, the surgeon may be able to perform a skin-sparing or nipple-sparing mastectomy. This means that more of the normal skin - with or without the nipple - is kept. It allows the surgeon to do an immediate breast reconstruction.
If you don't have an immediate reconstruction, you can wear a soft temporary breast prosthesis inside your bra while your surgical wound heals. After this time, you can be fitted for a permanent breast prosthesis.
Some women who need a mastectomy because of cancer in one breast choose to have the other breast removed as well. This surgery is known as a contralateral prophylactic mastectomy. Your surgeon may recommend a double mastectomy if you have the BRCA1 or BRCA2 gene mutation, because the mutation increases the risk of developing another breast cancer. Some women with average risk also choose to have a double mastectomy, even though it does not normally make any difference to survival rates.
A breast reconstruction is a type of surgery in which a breast shape is created using a silicone implant, tissue from another part of your body, or a combination of both.
Some women have a breast reconstruction at the same time as a mastectomy (immediate reconstruction). Others are advised or prefer to wait for several months or longer before having a reconstruction (delayed reconstruction). Some women choose not to have a reconstruction at any stage.
If you're not having an immediate reconstruction but might consider it in the future, discuss this with your surgeon before surgery, as it will help them to plan the mastectomy. See Breast Prostheses and Reconstruction.
"I was having a routine mammogram when they found a large lump. I had always had lumpy breasts but neither I nor my GP could feel this lump. I went for an ultrasound and while they were doing it, people just kept coming in and I thought, "Oh, okay, everyone's taking a lot of interest in this." The biopsies then confirmed that it was cancer.
"I'd had benign breast lumps and biopsies practically my whole life, so I'd already had a strategy that if they found something, I was just going to have a mastectomy on both sides. And so once I did get my diagnosis, that was my plan. Certainly the tumour looked too large to just do a lumpectomy or do any saving of the breast tissue.
"Of course, they wanted to do everything in two weeks and so that is a bit head-spinning. I just sort of thought, "Well, great I'll have my breasts removed. End of checklist." But then they found I had positive lymph nodes and I needed to have full axillary clearance on the right. I think that was the most daunting because it meant it had spread and I was also worried about the lymphoedema risk.
"I really felt like I was spiralling out of control at that point and knew I needed to learn some anxiety management - the breast care nurses and the Cancer Council relaxation and meditation CDs really helped with that.
"After the surgery, I started seven months of chemotherapy. And then I had five weeks of radiation therapy. I was lucky I could have it close to home - it made such a difference not having to travel.
"I chose the bilateral mastectomy because I was so busty, it would have been odd to have just one done. Although, having said that, I would now always encourage someone to do the least amount of surgery that they're advised to do. Because things have changed even in the five years since I had my surgery."
Tell your cancer story.
Removing lymph nodes
The lymph nodes in the armpit (axillary lymph nodes) are often the first place breast cancer cells spread to outside the breast. To see whether the cancer has spread, some or all of the lymph nodes are removed and checked for cancerous cells.
The operation to remove lymph nodes is called axillary surgery. It is usually performed during breast surgery, but may be done in a separate operation. There are two main types of axillary surgery:
Sentinel node biopsy
When breast cancer first spreads beyond the breast, it is likely to go to particular lymph nodes in the armpit or sometimes near the breastbone (sternum). There may be one, two or a few of these lymph nodes, which are known as the sentinel nodes. A sentinel node biopsy finds and removes them so they can be tested for cancer cells. The procedure is outlined below.
If the sentinel nodes are clear of cancer cells, no further surgery is needed. If one or more sentinel nodes contain cancer cells, axillary dissection or radiation therapy to the armpit may be considered.
Axillary dissection (clearance)
The surgeon will remove most or all of the axillary lymph nodes (usually 10-20 nodes). If they contain cancer cells, your doctor may recommend chemotherapy, radiation therapy, targeted therapy and/or hormone therapy.
Possible side effects of both types of axillary surgery include: arm or shoulder stiffness; numbness in the arm, shoulder, armpit and parts of the chest; lymphoedema; and seroma (fluid collecting near the surgical scar). However, these side effects are usually less severe after a sentinel node biopsy than after axillary dissection because fewer lymph nodes are removed. Your surgeon will discuss the potential side effects with you before the operation and explain how they can be managed.
Finding the sentinel nodes
To work out which lymph nodes are the sentinel nodes, you may have the following procedures:
- Lymphatic mapping – This is done either the day before or on the morning before the biopsy. A small amount of a radioactive substance is injected into the breast. A scan is taken to show which nodes the substance flows to first. These are likely to be the sentinel nodes.
- Blue dye injection (not always used) – For the biopsy, you will have a general anaesthetic. If blue dye is being used, it will be injected into the breast. The dye moves into the lymphatic vessels and stains the sentinel nodes blue first. Because of the dye, you will have bluish urine the next day and may have a blue patch on the breast for some weeks.
- Handheld probe – As well as looking at where the blue dye travels to first, the surgeon uses a handheld probe during the operation to detect the radioactive substance that was injected during the lymphatic mapping. This helps to confirm that the correct sentinel nodes have been identified and the surgeon can then remove them for testing.
What to expect after breast surgery
How long you stay in hospital will depend on the type of surgery you have and how well you recover. Most people can walk around and shower the day after surgery. If you have any questions about your recovery, ask the doctors and nurses caring for you. Many people are referred to a breast care nurse for information and support.
Tubes and dressings
You may have one or more drainage tubes in place to remove fluid from the surgical site. These may remain in place for up to 10 days, depending on the type of surgery. A dressing will cover the wound to keep it clean, and it will usually be removed after about a week.
Some people are discharged from hospital with drains still in place, but this will depend on your situation and your doctor's advice. Nursing staff will teach you how to manage the drains at home, or you may be referred to a community nurse or your GP.
While you are in hospital, you will be advised to move your legs when you are in bed to help prevent blood clots, and to get up and walk around when you are able. You may have to wear elastic (compression) stockings or use other devices to help prevent blood clots in the deep veins of your legs (deep vein thrombosis or DVT). Your doctor might also prescribe medicine that lowers the risk of clots.
You will be given pain relief through an intravenous (IV) drip, via an injection, or as tablets, and you will be given pain medicine when you go home. Any bruising and swelling at the surgery site will usually settle down in 2-3 weeks.
Sense of loss
Breast surgery may change the appearance of your breast, and this can affect how you feel about yourself ( self-image and self-esteem). You may feel a sense of loss if you've had a mastectomy and find that your sense of identity or femininity has been affected. It is normal to grieve the loss of your breast.
Talking to someone who has had breast surgery might be helpful. Cancer Connect may be able to link you to someone who has had a similar experience to you. You may also benefit from speaking with a counsellor or psychologist for emotional support and coping strategies. Call Cancer Council 13 11 20 for details.
Exercising your arm
After surgery, ask your treatment team when you can slowly begin to exercise your arm and shoulder. This will help it feel better and get back to normal faster. Arm and shoulder exercises will also move any fluid that has collected near the surgical scar (seroma) and help to prevent lymphoedema.
You can also download information about arm & shoulder exercises after surgery
What to expect when you get home
Recovering from breast surgery will take time. If you need home nursing care, ask hospital staff about services that are available in your area.
Getting back on your feet
The time it takes to recover from breast surgery varies. Most people start to feel better within about two weeks.
Get plenty of rest in the first few days after being discharged from hospital. Take it easy and do only what is comfortable.
Ask friends or family to help you out while you recover, e.g. with household chores, meals or errands.
Check with your surgeon and/or breast care nurse about when you can start doing your regular activities. For example, some surgeons tell you to avoid driving until the stitches are removed or until your arm is more agile.
Caring for the wound
Talk to your surgeon and breast care nurse about the best way to look after the wound.
Report any redness, pain, fever, swelling or wound discharge to your surgeon or breast care nurse.
Talk to your treatment team if you want to shave your armpits. They may advise you to wait for a time.
Keep the wound clean, and gently pat it dry after showering.
If you want to wear a bra, choose a soft bra or crop top. A sterile gauze pad placed inside your bra may help with rubbing on any tender areas.
Gently massage the area with moisturiser once the stitches have been removed and the wound has completely healed.
Don't use deodorant
If the wound is under your arm, avoid using deodorant until it has completely healed.
Side effects of surgery
Talk to your doctor or breast care nurse about ways to deal with the side effects of surgery. Most side effects can be managed. For more information, see Living with breast cancer.
Feeling tired and having no energy is common. Cancer treatment and the emotional impact of the diagnosis can be tiring. Fatigue may continue for a few weeks or months. There is evidence that exercise during and after cancer treatment can help improve fatigue.
See Exercise for People Living with Cancer or call Cancer Council 13 11 20 to find out about exercise programs. YWCA Encore is a free exercise program for women who have had breast cancer surgery - visit ywcaencore.org.au or call 1800 305 150.
Gentle arm and shoulder exercises can help prevent or manage shoulder stiffness. Talk to your health care team and see exercising your arm for more information about these exercises.
Numbness and tingling
Surgery can cause bruising or injury to nerves, which may cause numbness and tingling in the chest and arm. This often improves within a few weeks, but it may take longer. For some people, it may not go away completely. A physiotherapist or occupational therapist can suggest exercises that may help.
Fluid may collect in or around the surgical scar. A breast care nurse, your specialist or GP, or a radiologist can drain the fluid using a fine needle and a syringe. This procedure isn't painful, but it may need to be repeated over a few appointments.
Change in breast, nipple or arm sensation
This is usually temporary, but it may be permanent for some people.
Fluid build-up may cause swelling in the arm or breast after lymph node surgery or radiation therapy. See ways to manage lymphoedema.
Chemotherapy uses drugs to kill cancer cells or slow their growth. It is usually given before radiation therapy and may be used if:
- the cancer needs to be shrunk or controlled before surgery (neoadjuvant chemotherapy)
- the cancer is not sensitive to hormone therapy and/or is HER2 positive
- the risk of the cancer returning is high the cancer returns after surgery or radiation therapy (to gain control of the cancer and relieve symptoms).
Many different types of chemotherapy drugs are used to treat early and locally advanced breast cancer. The drug combination you are given will depend on the type of cancer, how far it has spread and what other treatments you are having. Common drugs include doxorubicin, cyclophosphamide, fluorouracil, docetaxel and paclitaxel. Your health professionals may also refer to the drugs by their brand names.
Chemotherapy is given through a vein (intravenously). You will usually be treated as an outpatient, but occasionally you may have to stay in hospital overnight.
Most people will have chemotherapy for 3-6 months. Some drugs are given once every three weeks, others are given on a faster schedule (e.g. once every two weeks or once a week). Not every person with breast cancer will have the same chemotherapy treatment on the same schedule.
Side effects of chemotherapy
Chemotherapy damages cells as they divide. This makes the drugs effective against cancer cells, which divide rapidly. However, some normal cells - such as hair follicles, blood cells and cells inside the mouth or bowel - also divide rapidly. Side effects happen when chemotherapy damages these normal cells. Unlike cancer cells, normal cells can recover, so most side effects are temporary. Side effects can often be prevented or managed by your treatment team.
Most people who have chemotherapy for breast cancer lose their head and facial hair. Some treatment centres provide cold caps, which may prevent total head hair loss, but this depends on the drugs used. For information about cold caps, speak to your treatment team. See information about wigs.
Some women find that their periods become irregular or stop during chemotherapy. Periods may return to normal after treatment, or they may stop permanently ( menopause), causing infertility. For men, chemotherapy can lower the number of sperm produced, which can cause temporary or permanent infertility. If you may want to consider having children in the future, talk to your cancer specialists about the options and ask for a referral to a fertility specialist before your treatment starts.
Other side effects
Common side effects include tiredness, mouth ulcers, nausea and vomiting, and constipation. Chemotherapy can also lower your immune system, increasing the risk of infection. Some people experience pins and needles (peripheral neuropathy). See Understanding Chemotherapy.
Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams.
Radiation therapy is recommended:
- after breast-conserving surgery to help destroy any undetected cancer cells that may be in the breast and to reduce the risk of the cancer coming back
- sometimes after a mastectomy, depending on the risk of the cancer coming back in the chest area
- if lymph nodes from under the arm were removed and the risk of the cancer coming back in this area is considered to be high.
You will usually start radiation therapy about four weeks after surgery. If you're having chemotherapy after surgery, radiation therapy will begin about four weeks after chemotherapy has finished.
Planning radiation therapy
Treatment is carefully planned to have the greatest effect on the cancer cells and to limit damage to the surrounding healthy tissues. Planning involves several steps, which may occur over a few visits.
You will have a planning session at the radiation therapy centre. During this appointment, you will have a CT scan to pinpoint the area to be treated, and marks will be put on your skin so the radiation therapists treat the same area each time. These marks are small dots (tattoos), and they may be temporary or permanent. Talk to your radiation therapists if you are worried about these tattoos.
Having radiation therapy
You will probably have radiation therapy daily from Monday to Friday for 3-6 weeks. In some cases, you may have a larger dose each day for about three weeks. Usually you can have radiation therapy as an outpatient and go to the treatment centre each day.
Each radiation therapy session will be in a treatment room. Although you will get radiation for only 1-5 minutes, setting up the machine can take 10-30 minutes. You will lie on a table under the machine. The radiation therapists will leave the room and then switch on the machine, but you can talk to them through an intercom. Radiation therapy is not painful, but you will need to lie still while the treatment is given.
Side effects of radiation therapy
Radiation therapy may cause the following side effects:
You may feel tired or fatigued (lacking energy for dayto-day activities) 1-2 weeks after radiation therapy starts, and during treatment. This usually eases a few weeks after treatment finishes.
Red and dry skin
The skin at the treatment site may become red and dry after a few weeks of treatment. It usually returns to normal 4-6 weeks after treatment ends. The nurses will show you how to care for your skin. Sorbolene cream applied twice a day can be helpful.
Inflammation and blistering
Less commonly, your skin may become itchy and/or very irritated. This will be closely monitored by the treatment team, who will recommend creams to apply to the area.
You may feel minor aches or shooting pains that last for a few moments during treatment.
Some people develop fluid in the breast (breast oedema) that can last for up to 12 months or, in some cases, up to five years. Radiation therapy to the armpit may increase the chance of developing lymphoedema in the arm. Talk to your radiation oncologist or radiation oncology nurse about any changes you experience.
Radiation therapy to the breast does not cause you to lose hair from your head, although you may lose hair from the treated armpit. The radiation does not stay in your body during or after treatment, so it is safe for you to spend time with family and friends. See Understanding Radiation Therapy.
If you live in a regional or rural area, you may need to travel for radiation therapy. Patient assisted travel schemes (PATS) may help with the cost of travel and accommodation. For details, talk to the hospital social worker or call Cancer Council 13 11 20.
Hormone therapy, also called endocrine therapy or hormoneblocking therapy, is used to treat hormone receptor positive cancers ( ER+ and/or PR+). The aim of hormone therapy is to slow or stop the growth of hormone receptor positive cancer cells.
There are different ways to reduce the level of female hormones in the body. The choice will depend on your age, the type of breast cancer and - for women - whether you have reached menopause.
Tamoxifen is known as an anti-oestrogen drug. It works by stopping cancer cells from responding to oestrogen. Treatment with tamoxifen is usually started after surgery, radiation therapy or chemotherapy. It is commonly taken as a daily tablet for 5-10 years. It can be given to women of any age, regardless of whether they have reached menopause, and to men.
Your doctor will probably recommend using contraception while taking tamoxifen, as the drug may be harmful to a developing baby. In women, tamoxifen can cause menopausal symptoms, although it does not cause menopause. In men, the side effects can include low sex drive (libido) and erection problems.
You may also be at an increased risk of blood clots - see your doctor immediately if you have any swelling, soreness or warmth in an arm or leg. If you are having further surgery or travelling long distances, you may need to stop taking tamoxifen beforehand to lower the risk of blood clots. You can start taking it again when surgery or travel is completed.
A rare side effect is a higher risk of uterine cancer in postmenopausal women, so see your doctor if you notice any unusual vaginal bleeding.
You will probably not experience all of these side effects. Side effects usually improve as treatment continues and after it has finished. Your doctor and breast care nurse can give you information about ways to manage the side effects of tamoxifen.
Aromatase inhibitors help prevent the growth of hormone sensitive cancer cells by reducing the amount of oestrogen the body produces. They are recommended only for postmenopausal women, who are already producing smaller amounts of oestrogen. Before starting treatment with an aromatase inhibitor, you will have a bone density scan to check your bone health. Examples of aromatase inhibitors include anastrozole, exemestane and letrozole. They are taken daily as a tablet, usually for 5-10 years.
Side effects of aromatase inhibitors may include joint and muscle pain, bone thinning and weakening (osteoporosis), vaginal dryness, low mood, hot flushes and weight gain. For women with arthritis, aromatase inhibitors may worsen joint stiffness and pain. Exercise or medicines from your doctor may help with this.
For women who have not reached menopause, there are treatments that can stop the ovaries from producing oestrogen, either temporarily or permanently. These are sometimes recommended as an additional treatment for women taking tamoxifen.
Temporary ovarian treatment
Also known as ovarian suppression, this treatment includes the drug goserelin (brand name Zoladex), which stops oestrogen production. The drug is given as an injection by a nurse or your GP once a month for 2-5 years to bring on a temporary menopause. Side effects are similar to those of permanent menopause.
Permanent ovarian treatment
Ovarian ablation is treatment that permanently stops the ovaries from producing oestrogen. It usually involves surgery to remove the ovaries (oophorectomy). Ovarian ablation will bring on permanent menopause. This means you will no longer be able to become pregnant. If you may want to become pregnant in the future, ask your doctor for a referral to a fertility specialist before treatment starts. See Fertility and Cancer for more about menopause.
Targeted therapy uses drugs that work in a different way to chemotherapy drugs. While chemotherapy affects all rapidly dividing cells, targeted therapy attacks specific targets inside cancer cells.
The targeted therapy drugs that are currently available do not work for all types of breast cancer. They are useful only for breast cancers that are growing in response to the HER2 protein. These HER2 positive breast cancers make up about 15-20% of all breast cancers. For early or locally advanced breast cancer in both women and men, the main targeted therapy drug is trastuzumab (brand name Herceptin). Other drugs are available for advanced breast cancer.
Trastuzumab is usually referred to by the brand name Herceptin. This targeted therapy works by attaching itself to HER2 positive breast cancer cells, destroying the cells or reducing their ability to divide and grow. Herceptin also encourages the body's own immune cells to help destroy the cancer cells.
Herceptin is used together with chemotherapy. It has been shown to increase the effect of chemotherapy drugs on early breast cancer. Some people receive Herceptin as an injection, but others are given it via a drip into a vein (infusion). You will usually have a dose every three weeks, although some people may have weekly doses.
The first infusion will take up to 90 minutes. This is called the loading dose. The following infusions take 30-60 minutes each, and they will continue for up to 12 months. The first four doses are given while you are having chemotherapy treatment.
Your medical team will monitor you for side effects. Often these will be caused by the chemotherapy. This means that once chemotherapy finishes and you are continuing with Herceptin for another nine months, most side effects ease. For example, hair grows back, there is no nausea or vomiting, and you no longer need regular blood tests.
Although side effects from the Herceptin itself are uncommon, they can include fever, diarrhoea, headache and a rash. In some people, Herceptin can affect how the heart works, so you will have tests to check your heart function before and during treatment. Ask your doctor for more information about these tests.
Key points about treatment for early or locally advanced breast cancer
Choice of treatment
The treatments you are offered will depend on many factors, such as your test results, whether the cancer is hormone receptor positive and/or HER2 positive or triple negative, and your age.
Surgery is the main treatment for most early or locally advanced breast cancers. You may be offered:
- breast-conserving surgery - removes only the cancerous part of the breast
- mastectomy - removes the whole breast
- breast reconstruction - re-creates the shape of your breast during or after a mastectomy; some women choose not to have this surgery or to delay it
- axillary surgery - removes some or all of the lymph nodes from the armpit to check if they are cancerous; can be done through a sentinel node biopsy or axillary dissection.
You may also have other types of treatments, such as:
- chemotherapy - use of drugs to damage cancer cells
- radiation therapy - use of targeted radiation to damage cancer cells
- hormone therapy - use of tamoxifen, aromatase inhibitors or ovarian treatments to block oestrogen, used for ER+ and/or PR+ breast cancer
- targeted therapy - use of the drug trastuzumab (Herceptin) for HER2+ breast cancer.
Expert content reviewers:
Prof Christobel Saunders, Professor of Surgical Oncology and Head, Division of Surgery, The University of Western Australia, and Consultant Surgeon, Royal Perth, Fiona Stanley and St John of God Subiaco Hospitals, WA; Dr Marie-Frances Burke, Radiation Oncologist, Medical Director, Genesis CancerCare Queensland, QLD; Kylie Campbell, Breast Care Nurse and Clinical Lead, Murraylands, McGrath Foundation, SA; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland, QLD; Annmaree Mitchell, Consumer; Sarah Pratt, Nurse Coordinator, Breast Service, Peter MacCallum Cancer Centre, VIC; Dr Wendy Vincent, Breast Physician, Chris O'Brien Lifehouse and Royal Hospital for Women, Randwick, NSW, and Clinical Director BreastScreen NSW, Royal Prince Alfred Hospital, NSW; A/Prof Nicholas Wilcken, Director of Medical Oncology, Westmead Hospital, and Co-ordinating Editor, Cochrane Breast Cancer Group, NSW.