Patient Assessment and Clinical Staging

The assessment of a patient with breast cancer involves taking a focused history. This includes identification of both the modifiable and non-modifiable risk factors for breast cancer that the patient carries. Most of the modifiable risk factors are related to estrogen. Non-modifiable risk factors include family history and precursor lesions. Physical examination of the breasts and lymph nodes must be performed. Both mammography and ultrasound are typically utilized to image the breasts, with higher diagnostic accuracy associated with concomitant use. Breast MRI is generally reserved for high-risk patients, with its use not otherwise shown to increase survival. Staging imaging to assess for metastatic disease is recommended for locally advanced and recurrent breast cancer and those with symptoms of metastatic disease. Lesions suspicious for cancer on imaging, as classified by the BI-RADS scoring system, should be biopsied. Core-needle biopsy is preferred over fine-needle aspiration because of its higher diagnostic accuracy. The results of the biopsy should be concordant with imaging and clinical findings or must be repeated. The AJCC Breast Cancer staging system can then be used to clinically stage and prognosticate the patient based on the results from the clinical exam, imaging, and biopsy.