Staging Investigations for Breast Cancer

Essential Baseline Workup for All Patients

The European Society for Medical Oncology recommends a complete personal and family history, physical examination including assessment of menopausal status for all newly diagnosed breast cancer patients 3
The European Society for Medical Oncology suggests laboratory tests including complete blood count, liver and renal function tests, alkaline phosphatase, and calcium levels for all newly diagnosed breast cancer patients 3, 1, 2
Bilateral mammography and ultrasound of breasts and regional lymph nodes are recommended by the European Society for Medical Oncology for all newly diagnosed breast cancer patients 3, 1, 2
The European Society for Medical Oncology recommends core needle biopsy (preferably ultrasound or stereotactic-guided) to confirm invasive disease for all newly diagnosed breast cancer patients 3
Biomarker assessment including ER, PR, HER2 status, and proliferation markers (Ki67) from biopsy specimen is recommended by the European Society for Medical Oncology for all newly diagnosed breast cancer patients 3, 1, 2

The European Society for Medical Oncology does not recommend routine distant staging investigations for low-risk patients (Stage I, Stage II with ≤3 positive nodes) 1, 2
Chest CT, abdominal imaging (ultrasound, CT, or MRI), and bone scan are recommended by the European Society for Medical Oncology for high-risk patients requiring full staging 1, 2
The National Comprehensive Cancer Network recommends against routine distant staging investigations for patients with clinically positive axillary nodes, large tumors (≥5 cm), aggressive tumor biology, or clinical signs, symptoms, or laboratory abnormalities suggesting metastases 4, 5

The National Comprehensive Cancer Network recommends against the use of PET-CT for routine staging of early breast cancer due to high false-negative rates for small (<1 cm) or low-grade lesions and poor sensitivity for axillary nodes 4, 5, 6
The European Society for Medical Oncology suggests that PET-CT may be useful when conventional imaging is inconclusive or for high-risk patients (locally advanced/inflammatory disease) who are candidates for neoadjuvant chemotherapy 3, 1, 2

The European Society for Medical Oncology recommends mandatory cardiac ultrasound or MUGA scan before starting anthracyclines and/or trastuzumab 3, 1, 2

The European Society for Medical Oncology recommends offering BRCA1/BRCA2 testing to patients with strong family history of breast, ovarian, pancreatic, or high-grade/metastatic prostate cancer, or personal history of ovarian cancer, second breast cancer, or male sex 1, 2

The American College of Radiology confirms no survival benefit from intensive surveillance imaging in asymptomatic Stage I patients, and recommends against over-staging early disease 8
The National Comprehensive Cancer Network explicitly recommends against PET/PET-CT for early-stage disease due to low sensitivity and high false-positive rates 4, 5, 6

The European Society for Medical Oncology recommends that the surgical specimen must be evaluated according to pTNM system including number, location, and maximum diameter of tumors, total number of removed and positive lymph nodes with extent of metastases, histological type and grade, and biomarker analysis confirmation 3, 1, 2