604 CLINICAL | AJGP VOL. 48, NO. 9, SEPTEMBER 2019 © The Royal Australian College of General Practitioners 2019 Ghaith Bahjat Heilat, Meagan E Brennan, James French Background Breast cancer affects one in eight Australian women. While surgery, chemotherapy, radiotherapy and endocrine therapy are still the main treatments, there have been changes in the sequencing of treatment and advances in each therapy. The general practitioner (GP) is involved at each stage of the patient’s journey. Objective This article discusses the current approach to the management of early breast cancer. It focuses on changes in recent years and discusses the role of the GP in supporting women in their decision-making and treatment. Discussion Key changes include the increasing use of neoadjuvant chemotherapy, the development of advanced oncoplastic surgery and breast reconstruction techniques, the use of gene expression profiling and the recommendation for extended adjuvant endocrine therapy for up to 10 years. IN AUSTRALIA, BREAST CANCER is the most common cancer in women, affecting one in eight women by the age of 80. 1,2 Breast cancer incidence is now stable and mortality is decreasing, 3 due partly to early diagnosis and partly to advances in treatment. In the area of treatment, multidisciplinary care remains important as there are different options for sequencing of treatment, increasing the complexity of care. While surgery remains the first treatment recommended for a number of patients with early breast cancer, in an increasing proportion of cases, chemotherapy is recommended as the initial treatment. There are many advantages of this approach, including down-staging of the tumour to facilitate surgery, and gaining of prognostic information based on response to chemotherapy. Surgical techniques have improved with the evolution of oncoplastic surgery, developments in breast reconstruction techniques, and a more conservative approach to surgery for the axilla. Further advances in radiotherapy, chemotherapy and targeted therapies have improved treatment, and adjuvant endocrine therapy has a key role in the treatment of oestrogen receptor-positive (ER-positive) cancer. Gene expression profiling of primary tumours can help to guide medication treatment. The general practitioner (GP) has an important role at every stage of the patient’s breast cancer journey. This article discusses some of the recent key changes in the approach to breast cancer management, with a focus on the role of the GP. Treatment sequencing Breast cancer was among the first tumour types for which multidisciplinary care became routine and it is now well established as the standard of care. 4 Multidisciplinary care is increasingly important as breast cancer treatment becomes more complex. The multidisciplinary team includes medical, surgical and radiation oncologists and other medical specialists such as pathologists, radiologists and genetic oncologists. In addition, the roles of the breast care nurse and allied health professionals including psychologists, physiotherapists and lymphoedema therapists are key. The team should include regular liaison with the GP to ensure comprehensive and continuous care and to provide optimal support to the patient. The traditional treatment paradigm of surgery followed by chemotherapy followed by radiotherapy is often challenged. Different sequencing allows treatment to be individualised, tailoring it to the tumour biology and the patient’s unique situation and preferences. An example of this is offering chemotherapy first (‘neoadjuvant chemotherapy’; NACT). Research has classified breast cancer into five intrinsic subtypes on the basis of molecular testing (luminal A, luminal B, HER2 positive, ‘basal-like’ and ‘normal- like’) 5 and this can help guide treatment. Each type is associated with a particular phenotype and has a distinct behaviour, risk factors and sensitivity to systemic therapy that help in the selection of the appropriate regimens and medications. Update on the management of early-stage breast cancer