Chapter 7: Breast Cancer

Epidemiology

Pathology

Work-up

Ductal carcinoma in situ:

1. History and physical

2. Bilateral diagnostic mammogram

3. Pathology review with ER status

4. Consideration of breast MRI (optional)

5. Genetic counseling if patient is high risk for hereditary breast cancer

6. Assess distress and refer to supportive services

Stages I & II invasive breast cancer:

1. History and physical

2. Diagnostic bilateral mammogram

3. Pathology review with ER, PR, and HER2 status

4. Consider breast MRI (optional), with special considerations for mammographically occult tumors, lobular carcinomas, or evaluation of in situ component

5. Genetic counseling if the patient is at high risk for hereditary breast cancer

6. CBC with platelets, LFTs, and alkaline phosphatase, and/or targeted staging imaging if symptoms are present concerning for metastatic disease

7. Pregnancy testing and counseling for fertility concerns if premenopausal

8. Assess distress and refer to supportive services

Stage III invasive breast cancer:

1. History and physical

2. Diagnostic bilateral mammogram

3. Pathology review with ER, PR, and HER2 status

4. Consider breast MRI (optional), with special considerations for mammographically occult tumors, lobular carcinomas or evaluation of in situ component

5. Genetic counseling if the patient is at high risk for hereditary breast cancer

6. CBC with platelets, comprehensive metabolic panel (including LFTs) if symptoms are present concerning for metastatic disease

7. Consider bone scan, abdominal ± pelvis CT or US or MRI, and chest imaging. FDG PET/CT also may be helpful in situations where standard staging studies are equivocal or suspicious

8. Pregnancy testing and counseling for fertility concerns if premenopausal

9. Assess distress and refer to supportive services

Stage IV:

1. History and physical

2. Diagnostic bilateral mammogram if de novo metastatic disease

3. Determination of tumor ER, PR, and HER2 status on a metastatic biopsy if possible

4. Tumor biomarker testing for FDA-approved targeted therapies

5. CBC with platelets, comprehensive metabolic panel (including LFTs)

6. Diagnostic CT with contrast of chest, abdomen, and pelvis or MRI with contrast.

7. Bone scan to assess for skeletal metastases. FDG PET/CT also may be helpful in situations where standard staging studies are equivocal or suspicious. Brain MRI with contrast if suspicious CNS symptoms

8. Genetic counseling and testing for consideration of FDA-approved targeted therapies

9. Assess distress and refer to supportive services (ie, social work, palliative care)

10. Discuss goals of therapy, adopt ...