++
++
++
Work-up
Ductal carcinoma in situ:
History and physical
Bilateral diagnostic mammogram
Pathology review with ER status
Consideration of breast MRI (optional)
Genetic counseling if patient is high risk for hereditary breast cancer
Assess distress and refer to supportive services
Stages I & II invasive breast cancer:
History and physical
Diagnostic bilateral mammogram
Pathology review with ER, PR, and HER2 status
Consider breast MRI (optional), with special considerations for mammographically occult tumors, lobular carcinomas, or evaluation of in situ component
Genetic counseling if the patient is at high risk for hereditary breast cancer
CBC with platelets, LFTs, and alkaline phosphatase, and/or targeted staging imaging if symptoms are present concerning for metastatic disease
Pregnancy testing and counseling for fertility concerns if premenopausal
Assess distress and refer to supportive services
Stage III invasive breast cancer:
History and physical
Diagnostic bilateral mammogram
Pathology review with ER, PR, and HER2 status
Consider breast MRI (optional), with special considerations for mammographically occult tumors, lobular carcinomas or evaluation of in situ component
Genetic counseling if the patient is at high risk for hereditary breast cancer
CBC with platelets, comprehensive metabolic panel (including LFTs) if symptoms are present concerning for metastatic disease
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
Pregnancy testing and counseling for fertility concerns if premenopausal
Assess distress and refer to supportive services
Stage IV:
History and physical
Diagnostic bilateral mammogram if de novo metastatic disease
Determination of tumor ER, PR, and HER2 status on a metastatic biopsy if possible
Tumor biomarker testing for FDA-approved targeted therapies
CBC with platelets, comprehensive metabolic panel (including LFTs)
Diagnostic CT with contrast of chest, abdomen, and pelvis or MRI with contrast.
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
Genetic counseling and testing for consideration of FDA-approved targeted therapies
Assess distress and refer to supportive services (ie, social work, palliative care)
Discuss goals of therapy, adopt ...