NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on diagnosis
This summary covers advanced (stage 4) breast cancer.
Refer people using a suspected cancer pathway referral for breast cancer if they are:[193]
Aged ≥30 and have an unexplained breast lump with or without pain or
Aged ≥50 with any of the following symptoms in one nipple only:
Discharge
Retraction
Other changes of concern.
Consider a suspected cancer pathway referral for breast cancer in people:[193]
With skin changes that suggest breast cancer or
Aged ≥30 with an unexplained lump in the axilla.
Consider non-urgent referral in people aged <30 with an unexplained breast lump with or without pain. Consider discussion with a specialist if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed.[193]
Deep vein thrombosis is associated with several cancers including breast cancer. Assess people with deep vein thrombosis for additional features of cancer and consider urgent investigation or a suspected cancer pathway referral.[193]
The following should be assessed if advanced breast cancer is suspected:[194]
The presence and extent of visceral metastases (using a combination of plain radiography, ultrasound, CT scans and MRI) and metastases in the bones of the axial skeleton (using bone windows on a CT scan or MRI or bone scintigraphy)
The risk of pathological fracture of proximal limb bones in patients with evidence of bone metastases elsewhere (using bone scintigraphy and/or plain radiography).
MRI should be used to assess bony metastases if other imaging is equivocal for metastatic disease or if more information is needed (e.g., if there are lytic metastases encroaching on the spinal canal).[194]
Positron emission tomography fused with computed tomography (PET-CT) should only be used to make a new diagnosis of metastases for patients with breast cancer whose imaging is suspicious but not diagnostic of metastatic disease.[194]
On recurrence, reassessment of oestrogen receptor (ER) and human epidermal growth factor 2 receptor (HER2) status should be considered if a change in receptor status will lead to a change in management.[194]
Do not use:[194]
Bone scintigraphy to monitor the response of bone metastases to treatment
PET-CT to monitor advanced breast cancer.
Links to NICE guidance
Suspected cancer: recognition and referral (NG12) May 2025. https://www.nice.org.uk/guidance/ng12
Advanced breast cancer: diagnosis and treatment (CG81) February 2025. https://www.nice.org.uk/guidance/cg81
Key NICE recommendations on management
Refer to the full NICE guideline and your local drug formulary for further information when prescribing – including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').
Genetic testing in specialist genetic clinics should be offered to a person with breast cancer if their combined BRCA1 and BRCA2 mutation carrier probability is ≥10%.[24]
People at increased risk of breast cancer should be managed in line with the NICE guideline Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer (CG164).
Systemic disease-modifying therapy
Endocrine therapy should be offered as first-line treatment for the majority of patients with ER-positive advanced breast cancer. Options for endocrine therapy are as follows:[194]
Postmenopausal women (previously treated with tamoxifen or with no prior history of endocrine therapy) should be offered an aromatase inhibitor (either non-steroidal or steroidal)
Pre- and perimenopausal women (not previously treated with tamoxifen) should be offered tamoxifen and ovarian suppression as first-line treatment
Pre- and perimenopausal women (previously treated with tamoxifen who then experience disease progression) should be offered ovarian suppression
Men should be offered tamoxifen as first-line treatment.
Chemotherapy should be offered 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).[194]
These patients should be offered endocrine therapy following completion of chemotherapy.[194]
On disease progression, systemic sequential chemotherapy should be offered to the majority of patients with advanced breast cancer who have decided to be treated with chemotherapy.[194]
Combination chemotherapy should be considered to treat patients for whom a greater probability of response is important and who understand and are likely to tolerate the additional toxicity.[194]
For patients who are not suitable for anthracyclines (due to contraindications or prior anthracycline treatment either in the adjuvant or metastatic setting), systemic chemotherapy should be offered in the following sequence:[194]
First line: single-agent docetaxel
Second line: single-agent vinorelbine or capecitabine
Third line: single-agent capecitabine or vinorelbine (whichever was not used second line).
Gemcitabine in combination with paclitaxel is recommended as an option for treatment of metastatic breast cancer only when docetaxel monotherapy or docetaxel plus capecitabine are also considered appropriate.[194]
See the NICE guideline for information on other treatments for advanced breast cancer, including biological therapy.[194]
Managing complications
For information on identifying, preventing and managing lymphoedema, see the NICE guideline Early and locally advanced breast cancer: diagnosis and management (NG101).
All patients for whom cancer-related fatigue is a significant problem should be offered an assessment for treatable causative factors, with appropriate management offered as necessary.[194]
All patients experiencing cancer-related fatigue should be provided with information about, and timely access to, an exercise programme.[194]
All patients presenting with uncontrolled local disease should be assessed by a breast cancer multidisciplinary team.[194]
All patients with fungating tumours should be seen by a wound care team.[194]
A palliative care team should assess all patients with uncontrolled local disease.[194]
For bone metastases:[194]
Bisphosphonates should be considered for patients newly diagnosed with bone metastases to prevent skeletal-related events and reduce pain
External beam radiotherapy should be used to treat patients with bone metastases and pain
An orthopaedic surgeon should assess all patients at risk of a long bone fracture, to consider prophylactic surgery.
For brain metastases:[194]
Surgery followed by whole brain radiotherapy should be offered to patients who have a single or small number of potentially resectable brain metastases, a good performance status and who have no or well controlled other metastatic disease
Whole brain radiotherapy should be offered to patients for whom surgery is not appropriate, unless they have a very poor prognosis
Active rehabilitation should be offered to patients who have surgery and/or whole brain radiotherapy
Referral to specialist palliative care should be offered to patients for whom active treatment for brain metastases would be inappropriate.
© NICE (2023) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer (CG164) November 2023. https://www.nice.org.uk/guidance/cg164
Advanced breast cancer: diagnosis and treatment (CG81) February 2025. https://www.nice.org.uk/guidance/cg81
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