Assessment Workflow
View More on Disease Algorithm-
1. Clinical presentation
Assess for a breast nodule, mass, abscess, pain, nipple discharge, nipple retraction, or skin changes.
-
2. History
Ask about breast pain, a new breast mass, and risk factors such as prior breast cancer, chest irradiation, and strong family history.
-
3. Physical examination
Inspect and palpate the breasts upright and supine; assess axillary, supraclavicular, and internal mammary lymph nodes and other organs for metastatic disease.
-
4. Imaging and biopsy
Use mammography and/or ultrasound, then biopsy suspicious findings; core needle biopsy is preferred for suspicious or indeterminate solid lesions on ultrasound.
-
5. Staging and biomarkers
Stage with TNM and test all newly diagnosed primary or metastatic cases for HER2; assess ER/PR and other tests when indicated.
Diagnosis
- Breast cancer is the presence of a malignant breast nodule, mass, or abscess.
- Patients commonly present with a new lump or mass in the breast.
- A complete breast examination includes inspection and palpation in upright and supine positions.
- Breast tissue biopsy is recommended if mammogram and/or ultrasound findings are suspicious or highly suggestive of malignancy.
- The TNM system is used for staging and determines extent of cancer upon diagnosis.[4][5][17]
Differential Diagnosis
| Differential diagnosis | Key Distinguishing Feature |
|---|---|
| Breast abscess | [22] |
| Breast cyst | [22] |
| Breast sarcoma | [22] |
| Fat necrosis | [22] |
| Fibroadenoma | [22] |
Diagnostics: Lab Tests and Imaging
| Test / Assessment | Clinical Purpose |
|---|---|
| Breast biopsy | Confirm malignancy when imaging is suspicious[5] |
| FNA cytology | Evaluate palpable lumps or selected nodes[5] |
| Core needle biopsy | Preferred tissue biopsy for suspicious lesions[5] |
| Sentinel node biopsy | Preferred axillary staging in early node-negative disease[5] |
| HER2 testing | Guide HER2-targeted therapy decisions[5] |
Pharmacological Management
| Treatment role | Therapy | Key note |
|---|---|---|
| Risk reduction | Tamoxifen | May be considered for ER-positive DCIS after breast conservation and radiotherapy.[27][28] |
| Risk reduction | Raloxifene | May be considered in postmenopausal patients with contraindications to tamoxifen.[27][28] |
| Adjuvant endocrine | Tamoxifen | First-line adjuvant endocrine therapy in pre- and postmenopausal patients.[27][28] |
| HER2-positive | Trastuzumab | Used after surgery, adjuvant or neoadjuvant chemotherapy, and radiotherapy if applicable.[27][28] |
| HER2-positive | Ado-trastuzumab emtansine | Used instead of trastuzumab if residual disease remains after preoperative therapy.[27][28] |
Dosage Guidelines
Raloxifene
Agent Affecting Bone MetabolismDosage: Risk reduction for invasive breast cancer in postmenopausal women: 60 mg PO 24 hourly
Tamoxifen
Cancer Hormone TherapyDosage: 20 mg/day PO in single dose or 40 mg/day PO divided 12 hourly
Fulvestrant
Cancer Hormone TherapyDosage: 250 mg slow IM injection, 1 in each buttock on days 1, 15, 29, then once monthly thereafter
Anastrazole
Cancer Hormone TherapyDosage: 1 mg PO 24 hourly; duration of treatment as adjuvant therapy: 5 years
Non-pharmacological management
- Staging determines the extent of cancer upon diagnosis and helps choose treatment.
- Preoperative systemic therapy may allow breast conservation and make inoperable tumors operable.
- Preoperative systemic therapy is indicated for inoperable locally advanced breast cancer, including inflammatory tumors, bulky or matted N2 axillary nodes, N3 disease, and/or T4 tumors.
- Surgery is part of risk reduction for carcinoma in situ, with breast conservation therapy and radiotherapy referenced in the management page.[27][28]
References
- Association of Breast Surgery @ BASO, Royal College of Surgeons of England. Guidelines for the management of symptomatic breast disease. Eur J Surg Oncol. 2005 May;31(Supp 1):1-21.
- Burnstein HJ. Tumor, node, metastasis (TNM) staging classification for breast cancer. UpToDate. Apr 2024.
- Gennari A, André F, Barrios CH, et al; ESMO Guidelines Committee. ESMO clinical practice guideline for the diagnosis, staging and treatment of patients with metastatic breast cancer. Ann Oncol. 2021 Dec;32(12):1475-1495. doi: 10.1016/j.annonc.2021.09.019. Accessed 11 Apr 2022. PMID: 34678411
- Kataja V, Castiglione M; ESMO Guidelines Working Group. Primary breast cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2009 May;20(Suppl 4):10-14. doi: 10.1093/annonc/mdp114. PMID: 19454421
- Ministry of Health Malaysia, Academy of Medicine Malaysia. Clinical practice guidelines. Management of breast cancer, 2nd edition. Nov 2010. Accessed 12 Sep 2012.
- Ministry of Health Malaysia, Academy of Medicine Malaysia. Clinical practice guidelines. Management of breast cancer. Third edition. Academy of Medicine Malaysia. 2019.
