History and physical examination should be undertaken to assess any physical signs and symptoms, which may suggest metastatic disease. History and physical exa should include examination of breasts, nodal basins (axillary, cervical, supraclavicular), lungs, liver and bones. If history and physical examination are normal, other staging investigations may not be necessary. If there are any abnormal findings, these should be further investigated as appropriate.
Investigations recommended prior to surgery include:
- Bilateral mammography
- Investigation of suspicious findings on history and physical exam
If the patient presents with locally advanced breast cancer (large tumour, node positive) or inflammatory breast cancer, the risk of metastatic disease is higher. Staging prior to any treatment (bone scan, chest CT or x-ray, abdominal CT or US and, laboratory investigations including liver enzymes) should be considered. In the absence of symptoms suggesting metastatic disease, staging should be done postoperatively based on final pathology.
Staging of breast cancer is based on final pathology. In asymptomatic patients with newly diagnosed cancer, the following staging investigations are recommended based on the pathologic staging:
|Stage 0 (DCIS)||No further investigations|
|Stage 1||Laboratory investigations (CBC, liver enzymes)|
|Stage 2||Laboratory investigations, consider bone scan, CXR, abdominal imaging |
|Stage 3||Laboratory investigations, CXR/Chest CT, abdominal imaging, bone scan|
Baseline tumour markers including CEA, CA15-3 and CA125 should only be considered as part of the initial staging for patients with metastatic disease. If normal, they need not be repeated, unless there is a documented or suspected progression.
Other than these investigations, prior to chemotherapy, a hematology and chemistry panel should be done to rule out bone or liver metastases and to ensure adequate marrow, hepatic and renal function.