Sections

Breast Cancer

DDx

Diagnostic Considerations

The differential diagnosis includes the following:

Circumscribed breast lesions – Benign breast disease (eg, fibroadenomas and cysts), breast cancer, breast lymphoma, and metastasis to the breast from other primary sites (eg, neuroendocrine or extramedullary acute myeloid leukemia)
Skin thickening and/or redness– Inflammatory carcinoma and mastitis
Stellate lesions – Breast cancer, traumatic fat necrosis, a radial scar, and a hyalinized fibroadenoma
Dilated ducts with or without nipple discharge – Papilloma, ductal carcinoma, duct ectasia, and fibrocystic disease

Differential Diagnoses

Workup

Breast Cancer Signs and Symptoms. American Cancer Society. Available at https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/breast-cancer-signs-and-symptoms.html. January 14, 2022; Accessed: August 17, 2023.
Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network. Available at https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf. Version 1.2023 — June 19, 2023; Accessed: August 17, 2023.
American Cancer Society Recommendations for the Early Detection of Breast Cancer. American Cancer Society. Available at https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html. January 14, 2022; Accessed: August 17, 2023.
[Guideline] Qaseem A, Lin JS, Mustafa RA, Horwitch CA, Wilt TJ, Clinical Guidelines Committee of the American College of Physicians., et al. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2019 Apr 16. 170 (8):547-560. [QxMD MEDLINE Link]. [Full Text].
[Guideline] American Cancer Society Recommendations for the Early Detection of Breast Cancer. American Cancer Society. Available at https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html. January 14, 2022; Accessed: April 5, 2022.
[Guideline] Siu AL, U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016 Feb 16. 164 (4):279-96. [QxMD MEDLINE Link]. [Full Text].
PDQ Adult Treatment Editorial Board. Breast Cancer Treatment (Adult) (PDQ®): Health Professional Version. January 18, 2023. [QxMD MEDLINE Link]. [Full Text].
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May. 71 (3):209-249. [QxMD MEDLINE Link]. [Full Text].
Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023 Jan. 73 (1):17-48. [QxMD MEDLINE Link]. [Full Text].
The Cancer Genome Atlas Network. Comprehensive molecular portraits of human breast tumours. Nature. 2012 Oct 4. 490(7418):61-70. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001 Mar 1. 19 (5):1539-69. [QxMD MEDLINE Link].
Wen HY, Brogi E. Lobular Carcinoma In Situ. Surg Pathol Clin. 2018 Mar. 11 (1):123-145. [QxMD MEDLINE Link]. [Full Text].
Surveillance Epidemiology and End Results (SEER). Cancer Stat Facts: Female Breast Cancer. National Cancer Institute. Available at http://seer.cancer.gov/statfacts/html/breast.html#incidence-mortality. Accessed: August 17, 2023.
Jatoi I, Anderson WF, Rosenberg PS. Qualitative age-interactions in breast cancer: a tale of two diseases? doi: 10.1097/COC.0b013e3181844d1c. Am J Clin Oncol. 2008 Oct. 31(5):504-6. [QxMD MEDLINE Link].
Allott EH, Shan Y, Chen M, Sun X, Garcia-Recio S, Kirk EL, et al. Bimodal age distribution at diagnosis in breast cancer persists across molecular and genomic classifications. Breast Cancer Res Treat. 2020 Jan. 179 (1):185-195. [QxMD MEDLINE Link]. [Full Text].
Michailidou K, Lindström S, Dennis J, Beesley J, Hui S, et al. Association analysis identifies 65 new breast cancer risk loci. Nature. 2017 Oct 23. [QxMD MEDLINE Link].
Milne RL, Kuchenbaecker KB, Michailidou K, Beesley J, Kar S, et al. Identification of ten variants associated with risk of estrogen-receptor-negative breast cancer. Nat Genet. 2017 Oct 23. [QxMD MEDLINE Link].
FDA authorizes, with special controls, direct-to-consumer test that reports three mutations in the BRCA breast cancer genes. U.S. Food & Drug Administration. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm599560.htm?utm_campaign=03062018_PR_23andme_BRCA&utm_medium=email&utm_source=Eloqua. March 6, 2018; Accessed: March 16, 2022.
Kelsey JL, Bernstein L. Epidemiology and prevention of breast cancer. Annu Rev Public Health. 1996. 17:47-67. [QxMD MEDLINE Link].
Colditz GA, Rosner B. Cumulative risk of breast cancer to age 70 years according to risk factor status: data from the Nurses' Health Study. Am J Epidemiol. 2000 Nov 15. 152(10):950-64. [QxMD MEDLINE Link].
Deligeoroglou E, Michailidis E, Creatsas G. Oral contraceptives and reproductive system cancer. Ann N Y Acad Sci. 2003 Nov. 997:199-208. [QxMD MEDLINE Link].
Colditz GA, Rosner BA, Chen WY, Holmes MD, Hankinson SE. Risk factors for breast cancer according to estrogen and progesterone receptor status. J Natl Cancer Inst. 2004 Feb 4. 96(3):218-28. [QxMD MEDLINE Link].
Pike MC, Pearce CL, Peters R, Cozen W, Wan P, Wu AH. Hormonal factors and the risk of invasive ovarian cancer: a population-based case-control study. Fertil Steril. 2004 Jul. 82(1):186-95. [QxMD MEDLINE Link].
Eliassen AH, Missmer SA, Tworoger SS, Spiegelman D, Barbieri RL, Dowsett M, et al. Endogenous steroid hormone concentrations and risk of breast cancer among premenopausal women. J Natl Cancer Inst. 2006 Oct 4. 98(19):1406-15. [QxMD MEDLINE Link].
Hankinson SE, Eliassen AH. Circulating sex steroids and breast cancer risk in premenopausal women. Horm Cancer. 2010 Feb. 1(1):2-10. [QxMD MEDLINE Link]. [Full Text].
Cuzick J, DeCensi A, Arun B, Brown PH, Castiglione M, Dunn B, et al. Preventive therapy for breast cancer: a consensus statement. Lancet Oncol. 2011 May. 12(5):496-503. [QxMD MEDLINE Link].
Fisher B, Costantino JP, Wickerham DL, Cecchini RS, Cronin WM, Robidoux A, et al. Tamoxifen for the prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst. 2005 Nov 16. 97(22):1652-62. [QxMD MEDLINE Link]. [Full Text].
Vogel VG, Costantino JP, Wickerham DL, Cronin WM, Cecchini RS, Atkins JN, et al. Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA. 2006 Jun 21. 295(23):2727-41. [QxMD MEDLINE Link].
Key T, Appleby P, Barnes I, Reeves G. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst. 2002 Apr 17. 94(8):606-16. [QxMD MEDLINE Link].
Santen RJ, Boyd NF, Chlebowski RT, Cummings S, Cuzick J, Dowsett M, et al. Critical assessment of new risk factors for breast cancer: considerations for development of an improved risk prediction model. Endocr Relat Cancer. 2007 Jun. 14(2):169-87. [QxMD MEDLINE Link].
Endogenous Hormones and Breast Cancer Collaborative Group. Free estradiol and breast cancer risk in postmenopausal women: comparison of measured and calculated values. Cancer Epidemiol Biomarkers Prev. 2003 Dec. 12(12):1457-61. [QxMD MEDLINE Link].
Marchbanks PA, McDonald JA, Wilson HG, Folger SG, Mandel MG, Daling JR, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002 Jun 27. 346(26):2025-32. [QxMD MEDLINE Link].
Garbe E, Levesque L, Suissa S. Variability of breast cancer risk in observational studies of hormone replacement therapy: a meta-regression analysis. Maturitas. 2004 Mar 15. 47(3):175-83. [QxMD MEDLINE Link].
Reeves GK, Beral V, Green J, Gathani T, Bull D. Hormonal therapy for menopause and breast-cancer risk by histological type: a cohort study and meta-analysis. Lancet Oncol. 2006 Nov. 7(11):910-8. [QxMD MEDLINE Link].
Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA. 2000 Jan 26. 283(4):485-91. [QxMD MEDLINE Link].
Speroff L. The Million Women Study and breast cancer. Maturitas. 2003 Sep 25. 46(1):1-6. [QxMD MEDLINE Link].
Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019 Sep 28. 394 (10204):1159-1168. [QxMD MEDLINE Link]. [Full Text].
Anderson GL, Chlebowski RT, Aragaki AK, Kuller LH, Manson JE, Gass M, et al. Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women's Health Initiative randomised placebo-controlled trial. Lancet Oncol. 2012 May. 13(5):476-86. [QxMD MEDLINE Link]. [Full Text].
Holmberg L, Anderson H. HABITS (hormonal replacement therapy after breast cancer--is it safe?), a randomised comparison: trial stopped. Lancet. 2004 Feb 7. 363(9407):453-5. [QxMD MEDLINE Link].
Loprinzi CL, Michalak JC, Quella SK, O'Fallon JR, Hatfield AK, Nelimark RA, et al. Megestrol acetate for the prevention of hot flashes. N Engl J Med. 1994 Aug 11. 331(6):347-52. [QxMD MEDLINE Link].
Bordeleau L, Pritchard K, Goodwin P, Loprinzi C. Therapeutic options for the management of hot flashes in breast cancer survivors: an evidence-based review. Clin Ther. 2007 Feb. 29(2):230-41. [QxMD MEDLINE Link].
Page DL, Jensen RA. Evaluation and management of high risk and premalignant lesions of the breast. World J Surg. 1994 Jan-Feb. 18(1):32-8. [QxMD MEDLINE Link].
Kollias J, Ellis IO, Elston CW, Blamey RW. Clinical and histological predictors of contralateral breast cancer. Eur J Surg Oncol. 1999 Dec. 25(6):584-9. [QxMD MEDLINE Link].
Page DL, Schuyler PA, Dupont WD, Jensen RA, Plummer WD Jr, Simpson JF. Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study. Lancet. 2003 Jan 11. 361(9352):125-9. [QxMD MEDLINE Link].
Page DL. Breast lesions, pathology and cancer risk. Breast J. 2004 Jan-Feb. 10 Suppl 1:S3-4. [QxMD MEDLINE Link].
Ashbeck EL, Rosenberg RD, Stauber PM, Key CR. Benign breast biopsy diagnosis and subsequent risk of breast cancer. Cancer Epidemiol Biomarkers Prev. 2007 Mar. 16(3):467-72. [QxMD MEDLINE Link].
Degnim AC, Visscher DW, Berman HK, Frost MH, Sellers TA, Vierkant RA, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort study. J Clin Oncol. 2007 Jul 1. 25(19):2671-7. [QxMD MEDLINE Link].
Dupont WD, Page DL, Parl FF, Vnencak-Jones CL, Plummer WD Jr, Rados MS, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med. 1994 Jul 7. 331(1):10-5. [QxMD MEDLINE Link].
Henderson BE, Bernstein L. The international variation in breast cancer rates: an epidemiological assessment. Breast Cancer Res Treat. 1991 May. 18 Suppl 1:S11-7. [QxMD MEDLINE Link].
Kaaks R. Nutrition, hormones, and breast cancer: is insulin the missing link?. Cancer Causes Control. 1996 Nov. 7(6):605-25. [QxMD MEDLINE Link].
Stoll BA. Breast cancer and the western diet: role of fatty acids and antioxidant vitamins. Eur J Cancer. 1998 Nov. 34(12):1852-6. [QxMD MEDLINE Link].
Holmes MD, Liu S, Hankinson SE, Colditz GA, Hunter DJ, Willett WC. Dietary carbohydrates, fiber, and breast cancer risk. Am J Epidemiol. 2004 Apr 15. 159(8):732-9. [QxMD MEDLINE Link].
Holmes MD, Willett WC. Does diet affect breast cancer risk?. Breast Cancer Res. 2004. 6(4):170-8. [QxMD MEDLINE Link]. [Full Text].
van den Brandt PA, Schulpen M. Mediterranean diet adherence and risk of postmenopausal breast cancer: results of a cohort study and meta-analysis. Int J Cancer. 2017 Mar 5. [QxMD MEDLINE Link]. [Full Text].
Eliassen AH, Colditz GA, Rosner B, Willett WC, Hankinson SE. Adult weight change and risk of postmenopausal breast cancer. JAMA. 2006 Jul 12. 296(2):193-201. [QxMD MEDLINE Link].
Han D, Nie J, Bonner MR, McCann SE, Muti P, Trevisan M, et al. Lifetime adult weight gain, central adiposity, and the risk of pre- and postmenopausal breast cancer in the Western New York exposures and breast cancer study. Int J Cancer. 2006 Dec 15. 119(12):2931-7. [QxMD MEDLINE Link].
Kaaks R. Nutrition, insulin, IGF-1 metabolism and cancer risk: a summary of epidemiological evidence. Novartis Found Symp. 2004. 262:247-60; discussion 260-68. [QxMD MEDLINE Link].
Lukanova A, Lundin E, Zeleniuch-Jacquotte A, Muti P, Mure A, Rinaldi S, et al. Body mass index, circulating levels of sex-steroid hormones, IGF-I and IGF-binding protein-3: a cross-sectional study in healthy women. Eur J Endocrinol. 2004 Feb. 150(2):161-71. [QxMD MEDLINE Link].
Baer HJ, Colditz GA, Rosner B, Michels KB, Rich-Edwards JW, Hunter DJ, et al. Body fatness during childhood and adolescence and incidence of breast cancer in premenopausal women: a prospective cohort study. Breast Cancer Res. 2005. 7(3):R314-25. [QxMD MEDLINE Link]. [Full Text].
Ruder EH, Dorgan JF, Kranz S, Kris-Etherton PM, Hartman TJ. Examining breast cancer growth and lifestyle risk factors: early life, childhood, and adolescence. Clin Breast Cancer. 2008 Aug. 8(4):334-42. [QxMD MEDLINE Link]. [Full Text].
Fuemmeler BF, Pendzich MK, Tercyak KP. Weight, dietary behavior, and physical activity in childhood and adolescence: implications for adult cancer risk. Obes Facts. 2009. 2(3):179-86. [QxMD MEDLINE Link]. [Full Text].
Laden F, Hunter DJ. Environmental risk factors and female breast cancer. Annu Rev Public Health. 1998. 19:101-23. [QxMD MEDLINE Link].
Coyle YM. The effect of environment on breast cancer risk. Breast Cancer Res Treat. 2004 Apr. 84(3):273-88. [QxMD MEDLINE Link].
Gammon MD, Eng SM, Teitelbaum SL, Britton JA, Kabat GC, Hatch M, et al. Environmental tobacco smoke and breast cancer incidence. Environ Res. 2004 Oct. 96(2):176-85. [QxMD MEDLINE Link].
Smith-Bindman R. Environmental causes of breast cancer and radiation from medical imaging: findings from the Institute of Medicine report. Arch Intern Med. 2012 Jul 9. 172(13):1023-7. [QxMD MEDLINE Link].
Smith-Warner SA, Spiegelman D, Yaun SS, van den Brandt PA, Folsom AR, Goldbohm RA, et al. Alcohol and breast cancer in women: a pooled analysis of cohort studies. JAMA. 1998 Feb 18. 279 (7):535-40. [QxMD MEDLINE Link].
Alcohol Use and Cancer. American Cancer Society. Available at https://www.cancer.org/cancer/risk-prevention/diet-physical-activity/alcohol-use-and-cancer.html. June 9, 2020; Accessed: August 17, 2023.
Boffetta P, Hashibe M. Alcohol and cancer. Lancet Oncol. 2006 Feb. 7 (2):149-56. [QxMD MEDLINE Link].
Carmichael A, Sami AS, Dixon JM. Breast cancer risk among the survivors of atomic bomb and patients exposed to therapeutic ionising radiation. Eur J Surg Oncol. 2003 Jun. 29(5):475-9. [QxMD MEDLINE Link].
Clemons M, Loijens L, Goss P. Breast cancer risk following irradiation for Hodgkin's disease. Cancer Treat Rev. 2000 Aug. 26(4):291-302. [QxMD MEDLINE Link].
Hill DA, Gilbert E, Dores GM, Gospodarowicz M, van Leeuwen FE, Holowaty E, et al. Breast cancer risk following radiotherapy for Hodgkin lymphoma: modification by other risk factors. Blood. 2005 Nov 15. 106(10):3358-65. [QxMD MEDLINE Link]. [Full Text].
Li CI, Daling JR. Changes in breast cancer incidence rates in the United States by histologic subtype and race/ethnicity, 1995 to 2004. Cancer Epidemiol Biomarkers Prev. 2007 Dec. 16(12):2773-80. [QxMD MEDLINE Link].
Glass AG, Lacey JV Jr, Carreon JD, Hoover RN. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy, screening mammography, and estrogen receptor status. J Natl Cancer Inst. 2007 Aug 1. 99(15):1152-61. [QxMD MEDLINE Link].
Jemal A, Ward E, Thun MJ. Recent trends in breast cancer incidence rates by age and tumor characteristics among U.S. women. Breast Cancer Res. 2007. 9(3):R28. [QxMD MEDLINE Link]. [Full Text].
Ravdin PM, Cronin KA, Howlader N, Berg CD, Chlebowski RT, Feuer EJ, et al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med. 2007 Apr 19. 356(16):1670-4. [QxMD MEDLINE Link].
Katalinic A, Rawal R. Decline in breast cancer incidence after decrease in utilisation of hormone replacement therapy. Breast Cancer Res Treat. 2008 Feb. 107(3):427-30. [QxMD MEDLINE Link].
Beral V. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet. 2003 Aug 9. 362(9382):419-27. [QxMD MEDLINE Link].
Anderson WF, Reiner AS, Matsuno RK, Pfeiffer RM. Shifting breast cancer trends in the United States. J Clin Oncol. 2007 Sep 1. 25(25):3923-9. [QxMD MEDLINE Link].
Evidence-based assessment of the impact of the WHI on women’s health. doi: 10.3109/13697137.2012.655564. Burger HG, MacLennan AH, Huang KE, Castelo-Branco C. Climacteric. 2012 Jun. 15(3):281-7.
American Cancer Society. Breast Cancer Facts & Figures 2022-2024. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/2022-2024-breast-cancer-fact-figures-acs.pdf. Accessed: January 31, 2023.
[Guideline] NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Version 4.2023 — March 23, 2023; Accessed: August 25, 2023.
Nassar H, Wallis T, Andea A, Dey J, Adsay V, Visscher D. Clinicopathologic analysis of invasive micropapillary differentiation in breast carcinoma. Mod Pathol. 2001 Sep. 14(9):836-41. [QxMD MEDLINE Link].
Rayson D, Adjei AA, Suman VJ, Wold LE, Ingle JN. Metaplastic breast cancer: prognosis and response to systemic therapy. Ann Oncol. 1999 Apr. 10(4):413-9. [QxMD MEDLINE Link].
Chao TC, Wang CS, Chen SC, Chen MF. Metaplastic carcinomas of the breast. J Surg Oncol. 1999 Aug. 71(4):220-5. [QxMD MEDLINE Link].
Chaudary MA, Millis RR, Lane EB, Miller NA. Paget's disease of the nipple: a ten year review including clinical, pathological, and immunohistochemical findings. Breast Cancer Res Treat. 1986. 8(2):139-46. [QxMD MEDLINE Link].
Kollmorgen DR, Varanasi JS, Edge SB, Carson WE 3rd. Paget’s disease of the breast: a 33-year experience. J Am Coll Surg. 1998 Aug. 187(2):171-7.
Mehta LS, Watson KE, Barac A, et al. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. Circulation. 2018 Feb 20. 137 (8):e30-e66. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Moyer VA. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013 Dec 24. [QxMD MEDLINE Link].
Xiao W, Zheng S, Yang A, Zhang X, Zou Y, Tang H, et al. Breast cancer subtypes and the risk of distant metastasis at initial diagnosis: a population-based study. Cancer Manag Res. 2018. 10:5329-5338. [QxMD MEDLINE Link]. [Full Text].
Berry DA, Cronin KA, Plevritis SK, Fryback DG, Clarke L, Zelen M, et al. Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 2005 Oct 27. 353(17):1784-92. [QxMD MEDLINE Link].
Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for breast cancer. JAMA. 2005 Mar 9. 293(10):1245-56. [QxMD MEDLINE Link]. [Full Text].
Moss SM, Wale C, Smith R, Evans A, Cuckle H, Duffy SW. Effect of mammographic screening from age 40 years on breast cancer mortality in the UK Age trial at 17 years' follow-up: a randomised controlled trial. Lancet Oncol. 2015 Jul 20. [QxMD MEDLINE Link].
Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014 Feb 11. 348:g366. [QxMD MEDLINE Link]. [Full Text].
García-Albéniz X, Hernán MA, Logan RW, Price M, Armstrong K, Hsu J. Continuation of Annual Screening Mammography and Breast Cancer Mortality in Women Older Than 70 Years. Ann Intern Med. 2020 Feb 25. [QxMD MEDLINE Link].
Brawley OW. On Mammography Screening for Women Older Than 70 Years. Ann Intern Med. 2020 Feb 25. [QxMD MEDLINE Link].
Nyström L, Andersson I, Bjurstam N, Frisell J, Nordenskjöld B, Rutqvist LE. Long-term effects of mammography screening: updated overview of the Swedish randomised trials. Lancet. 2002 Mar 16. 359(9310):909-19. [QxMD MEDLINE Link].
Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 2003 Apr 26. 361(9367):1405-10. [QxMD MEDLINE Link].
Noble M, Bruening W, Uhl S, Schoelles K. Computer-aided detection mammography for breast cancer screening: systematic review and meta-analysis. Arch Gynecol Obstet. 2009 Jun. 279(6):881-90. [QxMD MEDLINE Link].
Kleinknecht JH, Ciurea AI, Ciortea CA. Pros and cons for breast cancer screening with tomosynthesis - a review of the literature. Med Pharm Rep. 2020 Oct. 93 (4):335-341. [QxMD MEDLINE Link]. [Full Text].
Santos Aragon LN, Soto-Trujillo D. Effectiveness of Tomosynthesis Versus Digital Mammography in the Diagnosis of Suspicious Lesions for Breast Cancer in an Asymptomatic Population. Cureus. 2021 Mar 11. 13 (3):e13838. [QxMD MEDLINE Link]. [Full Text].
Chiarelli AM, Edwards SA, Prummel MV, Muradali D, Majpruz V, Done SJ, et al. Digital compared with screen-film mammography: performance measures in concurrent cohorts within an organized breast screening program. Radiology. 2013 May 14. [QxMD MEDLINE Link].
Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2016 Feb 16. 164 (4):244-55. [QxMD MEDLINE Link].
Ward E, Jemal A, Thun M. Regarding "Increase in breast cancer incidence in middle-aged women during the 1990s". Ann Epidemiol. 2005 Jul. 15(6):424-5; author reply 426-7. [QxMD MEDLINE Link].
Siu AL, U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016 Feb 16. 164 (4):279-96. [QxMD MEDLINE Link]. [Full Text].
Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP 3rd, et al. American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin. 2003 May-Jun. 53(3):141-69. [QxMD MEDLINE Link].
[Guideline] Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. October 20, 2015. 314:[Full Text].
[Guideline] Task Force Issues Draft Recommendation Statement on Screening for Breast Cancer. U.S. Preventive Services Task Force. Available at https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/breast-cancer-screening-draft-rec-bulletin.pdf. May 9, 2023; Accessed: May 10, 2023.
Expert Panel on Breast Imaging:., Mainiero MB, Moy L, Baron P, Didwania AD, diFlorio RM, et al. ACR Appropriateness Criteria^® Breast Cancer Screening. J Am Coll Radiol. 2017 Nov. 14 (11S):S383-S390. [QxMD MEDLINE Link]. [Full Text].
Alsheik N, Blount L, Qiong Q, Talley M, Pohlman S, Troeger K, et al. Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography. J Am Coll Radiol. 2021 Jul. 18 (7):906-918. [QxMD MEDLINE Link]. [Full Text].
Bernardi D, Macaskill P, Pellegrini M, Valentini M, Fantò C, Ostillio L, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-2): a population-based prospective study. Lancet Oncol. 2016 Aug. 17 (8):1105-13. [QxMD MEDLINE Link].
Kerlikowske K, Zhu W, Tosteson AN, Sprague BL, Tice JA, Lehman CD, et al. Identifying women with dense breasts at high risk for interval cancer: a cohort study. Ann Intern Med. 2015 May 19. 162 (10):673-81. [QxMD MEDLINE Link]. [Full Text].
ACR Practice Parameter for the Performance of a Diagnostic Breast Ultrasound Examination. American College of Radiology. Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/US-Breast.pdf. 2021; Accessed: April 7, 2022.
Sood R, Rositch AF, Shakoor D, Ambinder E, Pool KL, Pollack E, et al. Ultrasound for Breast Cancer Detection Globally: A Systematic Review and Meta-Analysis. J Glob Oncol. 2019 Aug. 5:1-17. [QxMD MEDLINE Link]. [Full Text].
Mann RM, Cho N, Moy L. Breast MRI: State of the Art. Radiology. 2019 Sep. 292 (3):520-536. [QxMD MEDLINE Link].
Breast MRI. American Cancer Society. Available at https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/breast-mri-scans.html. January 14, 2022; Accessed: April 6, 2022.
[Guideline] Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR. J Am Coll Radiol. 2018 Mar. 15 (3 Pt A):408-414. [QxMD MEDLINE Link].
Buist DSM, Abraham L, Lee CI, Lee JM, Lehman C, O'Meara ES, et al. Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer. JAMA Intern Med. 2018 Feb 12. [QxMD MEDLINE Link]. [Full Text].
Comstock CE, Gatsonis C , Newstead GM, et al. Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection Among Women With Dense Breasts Undergoing Screening. JAMA. 2020 Mar 24. 323 (12):1194. [QxMD MEDLINE Link]. [Full Text].
Taillefer R. Clinical applications of 99mTc-sestamibi scintimammography. Semin Nucl Med. 2005 Apr. 35(2):100-15. [QxMD MEDLINE Link].
[Guideline] Wolff AC, Hammond ME, Schwartz JN, Hagerty KL, Allred DC, Cote RJ, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007 Jan 1. 25(1):118-45. [QxMD MEDLINE Link].
[Guideline] Wolff AC, Hammond MEH, Allison KH, Harvey BE, Mangu PB, Bartlett JMS, et al. Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Clinical Practice Guideline Focused Update. J Clin Oncol. 2018 Jul 10. 36 (20):2105-2122. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Wolff AC, Somerfield MR, Dowsett M, Hammond MEH, Hayes DF, McShane LM, et al. Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: ASCO-College of American Pathologists Guideline Update. J Clin Oncol. 2023 Aug 1. 41 (22):3867-3872. [QxMD MEDLINE Link]. [Full Text].
Chen AC, Paulino AC, Schwartz MR, Rodriguez AA, Bass BL, Chang JC, et al. Prognostic markers for invasive micropapillary carcinoma of the breast: a population-based analysis. Clin Breast Cancer. 2013 Apr. 13(2):133-9. [QxMD MEDLINE Link].
Giuliano AE, Connolly JL, Edge SB, Mittendorf EA, Rugo HS, Solin LJ, et al. Breast Cancer-Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017 Mar 14. [QxMD MEDLINE Link]. [Full Text].
Hortobagyi GN, Connolly JL, D'Orsi CJ, et al. Breast. Amin MB, Edge SB, Greene FL, et al, eds. AJCC Cancer Staging Manual. Eighth ed. New York: Springer; 2017. 589-636.
[Guideline] Lyman GH, Somerfield MR, Bosserman LD, Perkins CL, Weaver DL, Giuliano AE. Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017 Feb 10. 35 (5):561-564. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Brackstone M, Baldassarre FG, Perera FE, Cil T, Chavez Mac Gregor M, Dayes IS, et al. Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline. J Clin Oncol. 2021 Sep 20. 39 (27):3056-3082. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Duffy MJ, Harbeck N, Nap M, Molina R, Nicolini A, Senkus E, et al. Clinical use of biomarkers in breast cancer: Updated guidelines from the European Group on Tumor Markers (EGTM). Eur J Cancer. 2017 Apr. 75:284-298. [QxMD MEDLINE Link]. [Full Text].
Sparano JA, Gray RJ, Makower DF, et al. Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer. N Engl J Med. 2018 Jul 12. 379 (2):111-121. [QxMD MEDLINE Link]. [Full Text].
Sparano JA, Gray RJ, Makower DF, et al. Clinical Outcomes in Early Breast Cancer With a High 21-Gene Recurrence Score of 26 to 100 Assigned to Adjuvant Chemotherapy Plus Endocrine Therapy: A Secondary Analysis of the TAILORx Randomized Clinical Trial. JAMA Oncol. 2019 Sep 30. [QxMD MEDLINE Link]. [Full Text].
Kalinsky K, Barlow WE, Gralow JR, et al. 21-Gene Assay to Inform Chemotherapy Benefit in Node-Positive Breast Cancer. N Engl J Med. 2021 Dec 16. 385 (25):2336-2347. [QxMD MEDLINE Link].
Jacobson A. Benefits of Adjuvant Chemotherapy Differ by Menopausal Status in Women with HR+/HER2- Early Breast Cancer, 1-3 Positive Nodes, and a Low Recurrence Score. Oncologist. 2022 Mar 28. 27 (Suppl 1):S15-S16. [QxMD MEDLINE Link]. [Full Text].
Piccart M, van 't Veer LJ, Poncet C, et al. 70-gene signature as an aid for treatment decisions in early breast cancer: updated results of the phase 3 randomised MINDACT trial with an exploratory analysis by age. Lancet Oncol. 2021 Apr. 22 (4):476-488. [QxMD MEDLINE Link]. [Full Text].
Dowsett M, Sestak I, Lopez-Knowles E, Sidhu K, Dunbier AK, Cowens JW, et al. Comparison of PAM50 risk of recurrence score with oncotype DX and IHC4 for predicting risk of distant recurrence after endocrine therapy. J Clin Oncol. 2013 Aug 1. 31 (22):2783-90. [QxMD MEDLINE Link].
Gnant M, et al; Austrian Breast and Colorectal Cancer Study Group. Predicting distant recurrence in receptor-positive breast cancer patients with limited clinicopathological risk: using the PAM50 Risk of Recurrence score in 1478 postmenopausal patients of the ABCSG-8 trial treated with adjuvant endocrine therapy alone. Ann Oncol. 2014 Feb. 25 (2):339-45. [QxMD MEDLINE Link].
Liu S, Chapman JA, Burnell MJ, Levine MN, Pritchard KI, Whelan TJ, et al. Prognostic and predictive investigation of PAM50 intrinsic subtypes in the NCIC CTG MA.21 phase III chemotherapy trial. Breast Cancer Res Treat. 2015 Jan. 149 (2):439-48. [QxMD MEDLINE Link].
Martin M, Brase JC, Ruiz A, Prat A, Kronenwett R, Calvo L, et al. Prognostic ability of EndoPredict compared to research-based versions of the PAM50 risk of recurrence (ROR) scores in node-positive, estrogen receptor-positive, and HER2-negative breast cancer. A GEICAM/9906 sub-study. Breast Cancer Res Treat. 2016 Feb. 156 (1):81-9. [QxMD MEDLINE Link].
Sestak I, Cuzick J, Dowsett M, Lopez-Knowles E, Filipits M, Dubsky P, et al. Prediction of late distant recurrence after 5 years of endocrine treatment: a combined analysis of patients from the Austrian breast and colorectal cancer study group 8 and arimidex, tamoxifen alone or in combination randomized trials using the PAM50 risk of recurrence score. J Clin Oncol. 2015 Mar 10. 33 (8):916-22. [QxMD MEDLINE Link].
Dubsky P, Filipits M, Jakesz R, Rudas M, Singer CF, Greil R, et al. EndoPredict improves the prognostic classification derived from common clinical guidelines in ER-positive, HER2-negative early breast cancer. Ann Oncol. 2013 Mar. 24 (3):640-7. [QxMD MEDLINE Link].
Martin M, Brase JC, Calvo L, Krappmann K, Ruiz-Borrego M, Fisch K, et al. Clinical validation of the EndoPredict test in node-positive, chemotherapy-treated ER+/HER2- breast cancer patients: results from the GEICAM 9906 trial. Breast Cancer Res. 2014 Apr 12. 16 (2):R38. [QxMD MEDLINE Link].
Filipits M, et al; EP Investigators. A new molecular predictor of distant recurrence in ER-positive, HER2-negative breast cancer adds independent information to conventional clinical risk factors. Clin Cancer Res. 2011 Sep 15. 17 (18):6012-20. [QxMD MEDLINE Link].
Sanft T, Aktas B, Schroeder B, Bossuyt V, DiGiovanna M, Abu-Khalaf M, et al. Prospective assessment of the decision-making impact of the Breast Cancer Index in recommending extended adjuvant endocrine therapy for patients with early-stage ER-positive breast cancer. Breast Cancer Res Treat. 2015 Dec. 154 (3):533-41. [QxMD MEDLINE Link].
[Guideline] Korde LA, Somerfield MR, Carey LA, Crews JR, Denduluri N, Hwang ES, et al. Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. J Clin Oncol. 2021 May 1. 39 (13):1485-1505. [QxMD MEDLINE Link]. [Full Text].
Neoadjuvant Endocrine Therapy May Elicit Differential Responses in Black vs White Women With Breast Cancer. ASCO Post. Available at https://ascopost.com/news/september-2022/neoadjuvant-endocrine-therapy-may-elicit-differential-responses-in-black-vs-white-women-with-breast-cancer/?utm_source=TAP%2DEN%2D092022&utm_medium=email&utm_term=046fca8ed7062b1f9d17ba521501b8c9. September 20, 2022; Accessed: September 20, 2022.
Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014 Nov. 15 (12):1303-10. [QxMD MEDLINE Link]. [Full Text].
Haviland JS, Owen JR, Dewar JA, et al, on behalf of the START Trialists' Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013 Sep 18. [QxMD MEDLINE Link].
[Guideline] Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer. Int J Radiat Oncol Biol Phys. 2014 Mar 1. 88(3):553-64. [QxMD MEDLINE Link].
[Guideline] American Society of Breast Surgeons. Consensus Guideline on Accelerated Partial Breast Irradiation. Available at https://www.breastsurgeons.org/about/statements/PDF_Statements/APBI.pdf. June 5, 2018; Accessed: January 17, 2019.
Smith GL, Jiang J, Buchholz TA, Xu Y, Hoffman KE, Giordano SH, et al. Benefit of adjuvant brachytherapy versus external beam radiation for early breast cancer: impact of patient stratification on breast preservation. Int J Radiat Oncol Biol Phys. 2014 Feb 1. 88(2):274-84. [QxMD MEDLINE Link].
Kuske RR, Young SS. Breast brachytherapy versus whole-breast irradiation: reported differences may be statistically significant but clinically trivial. Int J Radiat Oncol Biol Phys. 2014 Feb 1. 88(2):266-8. [QxMD MEDLINE Link].
Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Keshtgar M, et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2013 Nov 8. [QxMD MEDLINE Link].
Veronesi U, Orecchia R, Maisonneuve P, Viale G, Rotmensz N, Sangalli C, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013 Nov 8. [QxMD MEDLINE Link].
[Guideline] Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, et al. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Pract Radiat Oncol. 2016 Nov - Dec. 6 (6):e219-e234. [QxMD MEDLINE Link]. [Full Text].
Ebctcg Early Breast Cancer Trialists' Collaborative Group. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014 Mar 19. [QxMD MEDLINE Link].
Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet. 2015 Jul 23. [QxMD MEDLINE Link]. [Full Text].
Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma In Situ. JAMA Oncol. 2015 Aug 20. [QxMD MEDLINE Link]. [Full Text].
Esserman L, Yau C. Rethinking the Standard for Ductal Carcinoma In Situ Treatment. JAMA Oncol. 2015 Aug 20. [QxMD MEDLINE Link].
Allred DC, Anderson SJ, Paik S, Wickerham DL, Nagtegaal ID, Swain SM, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol. 2012 Apr 20. 30(12):1268-73. [QxMD MEDLINE Link]. [Full Text].
Phillips KA, Milne RL, Rookus MA, Daly MB, Antoniou AC, Peock S, et al. Tamoxifen and Risk of Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. J Clin Oncol. 2013 Sep 1. 31(25):3091-3099. [QxMD MEDLINE Link].
Margolese RG, Cecchini RS, Julian TB, Ganz PA, Costantino JP, Vallow LA, et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial. Lancet. 2016 Feb 27. 387 (10021):849-56. [QxMD MEDLINE Link]. [Full Text].
Gianni L, Pienkowski T, Im YH, Roman L, Tseng LM, Liu MC, et al. Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial. Lancet Oncol. 2012 Jan. 13(1):25-32. [QxMD MEDLINE Link].
Gianni L, Pienkowski T, Im YH, Tseng LM, Liu MC, Lluch A, et al. 5-year analysis of neoadjuvant pertuzumab and trastuzumab in patients with locally advanced, inflammatory, or early-stage HER2-positive breast cancer (NeoSphere): a multicentre, open-label, phase 2 randomised trial. Lancet Oncol. 2016 Jun. 17 (6):791-800. [QxMD MEDLINE Link]. [Full Text].
Tutt ANJ, Garber JE, Kaufman B, Viale G, et al. Adjuvant Olaparib for Patients with BRCA1- or BRCA2-Mutated Breast Cancer. N Engl J Med. 2021 Jun 24. 384 (25):2394-2405. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Giordano SH, Temin S, Chandarlapaty S, Crews JR, Esteva FJ, Kirshner JJ, et al. Systemic Therapy for Patients With Advanced Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2018 Sep 10. 36 (26):2736-2740. [QxMD MEDLINE Link]. [Full Text].
Bear HD, Anderson S, Smith RE, Geyer CE Jr, Mamounas EP, Fisher B, et al. Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer:National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2006 May 1. 24(13):2019-27. [QxMD MEDLINE Link].
[Guideline] Partridge AH, Rumble RB, Carey LA, Come SE, Davidson NE, Di Leo A, et al. Chemotherapy and Targeted Therapy for Women With Human Epidermal Growth Factor Receptor 2-Negative (or unknown) Advanced Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2014 Sep 2. [QxMD MEDLINE Link].
[Guideline] Burstein HJ, Somerfield MR, Barton DL, Dorris A, Fallowfield LJ, Jain D, et al. Endocrine Treatment and Targeted Therapy for Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Metastatic Breast Cancer: ASCO Guideline Update. J Clin Oncol. 2021 Dec 10. 39 (35):3959-3977. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Burstein HJ, DeMichele A, Somerfield MR, Henry NL, Biomarker Testing and Endocrine and Targeted Therapy in Metastatic Breast Cancer Expert Panels. Testing for ESR1 Mutations to Guide Therapy for Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Metastatic Breast Cancer: ASCO Guideline Rapid Recommendation Update. J Clin Oncol. 2023 Jun 20. 41 (18):3423-3425. [QxMD MEDLINE Link]. [Full Text].
Mehta RS, Barlow WE, Albain KS, Vandenberg TA, Dakhil SR, Tirumali NR, et al. Combination anastrozole and fulvestrant in metastatic breast cancer. N Engl J Med. 2012 Aug 2. 367(5):435-44. [QxMD MEDLINE Link]. [Full Text].
Robertson JFR, Bondarenko IM, Trishkina E, Dvorkin M, Panasci L, Manikhas A, et al. Fulvestrant 500 mg versus anastrozole 1 mg for hormone receptor-positive advanced breast cancer (FALCON): an international, randomised, double-blind, phase 3 trial. Lancet. 2016 Dec 17. 388 (10063):2997-3005. [QxMD MEDLINE Link]. [Full Text].
Bidard FC, Kaklamani VG, Neven P, Streich G, Montero AJ, Forget F, et al. Elacestrant (oral selective estrogen receptor degrader) Versus Standard Endocrine Therapy for Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer: Results From the Randomized Phase III EMERALD Trial. J Clin Oncol. 2022 Oct 1. 40 (28):3246-3256. [QxMD MEDLINE Link]. [Full Text].
Finn RS, Crown JP, Lang I, Boer K, Bondarenko IM, Kulyk SO, et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1/TRIO-18): a randomised phase 2 study. Lancet Oncol. 2015 Jan. 16(1):25-35. [QxMD MEDLINE Link].
Turner NC, Ro J, André F, Loi S, Verma S, Iwata H, et al. Palbociclib in Hormone-Receptor-Positive Advanced Breast Cancer. N Engl J Med. 2015 Jul 16. 373 (3):209-19. [QxMD MEDLINE Link]. [Full Text].
Hortobagyi GN, Stemmer SM, Burris HA, Yap YS, Sonke GS, Paluch-Shimon S, et al. Updated results from MONALEESA-2, a phase III trial of first-line ribociclib plus letrozole versus placebo plus letrozole in hormone receptor-positive, HER2-negative advanced breast cancer. Ann Oncol. 2018 Jul 1. 29 (7):1541-1547. [QxMD MEDLINE Link]. [Full Text].
Hortobagyi GN, Stemmer SM, Burris HA, Yap YS, Sonke GS, Paluch-Shimon S, et al. Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer. N Engl J Med. 2016 Nov 3. 375 (18):1738-1748. [QxMD MEDLINE Link].
Dickler MN, Tolaney SM, Rugo HS, Cortés J, Diéras V, Patt D, et al. MONARCH 1, A Phase II Study of Abemaciclib, a CDK4 and CDK6 Inhibitor, as a Single Agent, in Patients with Refractory HR⁺/HER2^- Metastatic Breast Cancer. Clin Cancer Res. 2017 Sep 1. 23 (17):5218-5224. [QxMD MEDLINE Link]. [Full Text].
Sledge GW Jr, Toi M, Neven P, Sohn J, Inoue K, Pivot X, et al. MONARCH 2: Abemaciclib in Combination With Fulvestrant in Women With HR+/HER2- Advanced Breast Cancer Who Had Progressed While Receiving Endocrine Therapy. J Clin Oncol. 2017 Sep 1. 35 (25):2875-2884. [QxMD MEDLINE Link]. [Full Text].
Goetz MP, et al. MONARCH 3: Abemaciclib As Initial Therapy for Advanced Breast Cancer. J Clin Oncol. 2017 Nov 10. 35 (32):3638-3646. [QxMD MEDLINE Link]. [Full Text].
Modi S, Saura C, Yamashita T, and the, DESTINY-Breast01 Investigators. Trastuzumab Deruxtecan in Previously Treated HER2-Positive Breast Cancer. N Engl J Med. 2019 Dec 11. [QxMD MEDLINE Link].
Tukysa (tucatinib) [package insert]. Bothell, WA: Seattle Genetics, Inc. April 2020. Available at [Full Text].
O'Shaughnessy J. Gemcitabine combination chemotherapy in metastatic breast cancer: phase II experience. Oncology (Williston Park). 2003 Dec. 17(12 Suppl 14):15-21. [QxMD MEDLINE Link].
Perez EA, Hillman DW, Stella PJ, Krook JE, Hartmann LC, Fitch TR, et al. A phase II study of paclitaxel plus carboplatin as first-line chemotherapy for women with metastatic breast carcinoma. Cancer. 2000 Jan 1. 88(1):124-31. [QxMD MEDLINE Link].
Jones SE, Savin MA, Holmes FA, O'Shaughnessy JA, Blum JL, Vukelja S, et al. Phase III trial comparing doxorubicin plus cyclophosphamide with docetaxel plus cyclophosphamide as adjuvant therapy for operable breast cancer. J Clin Oncol. 2006 Dec 1. 24(34):5381-7. [QxMD MEDLINE Link].
Miller K, Wang M, Gralow J, Dickler M, Cobleigh M, Perez EA, et al. Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N Engl J Med. 2007 Dec 27. 357(26):2666-76. [QxMD MEDLINE Link].
Slamon DJ, Neven P, Chia S, Fasching PA, De Laurentiis M, Im SA, et al. Phase III Randomized Study of Ribociclib and Fulvestrant in Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer: MONALEESA-3. J Clin Oncol. 2018 Aug 20. 36 (24):2465-2472. [QxMD MEDLINE Link]. [Full Text].
O'Shaughnessy J, Miles D, Vukelja S, Moiseyenko V, Ayoub JP, Cervantes G, et al. Superior survival with capecitabine plus docetaxel combination therapy in anthracycline-pretreated patients with advanced breast cancer: phase III trial results. J Clin Oncol. 2002 Jun 15. 20(12):2812-23. [QxMD MEDLINE Link].
Biganzoli L, Martin M, Twelves C. Moving forward with capecitabine: a glimpse of the future. Oncologist. 2002. 7 Suppl 6:29-35. [QxMD MEDLINE Link].
Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V, Bajamonde A, et al. Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. N Engl J Med. 2001 Mar 15. 344(11):783-92. [QxMD MEDLINE Link].
Marty M, Cognetti F, Maraninchi D, Snyder R, Mauriac L, Tubiana-Hulin M, et al. Randomized phase II trial of the efficacy and safety of trastuzumab combined with docetaxel in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer administered as first-line treatment: the M77001 study group. J Clin Oncol. 2005 Jul 1. 23(19):4265-74. [QxMD MEDLINE Link].
Burstein HJ, Kuter I, Campos SM, Gelman RS, Tribou L, Parker LM, et al. Clinical activity of trastuzumab and vinorelbine in women with HER2-overexpressing metastatic breast cancer. J Clin Oncol. 2001 May 15. 19(10):2722-30. [QxMD MEDLINE Link].
Geyer CE, Forster J, Lindquist D, Chan S, Romieu CG, Pienkowski T, et al. Lapatinib plus capecitabine for HER2-positive advanced breast cancer. N Engl J Med. 2006 Dec 28. 355(26):2733-43. [QxMD MEDLINE Link].
Albain KS, Nag SM, Calderillo-Ruiz G, Jordaan JP, Llombart AC, Pluzanska A, et al. Gemcitabine plus Paclitaxel versus Paclitaxel monotherapy in patients with metastatic breast cancer and prior anthracycline treatment. J Clin Oncol. 2008 Aug 20. 26(24):3950-7. [QxMD MEDLINE Link].
André F, Ciruelos E, Rubovszky G, Campone M, Loibl S, Rugo HS, et al. Alpelisib for PIK3CA-Mutated, Hormone Receptor-Positive Advanced Breast Cancer. N Engl J Med. 2019 May 16. 380 (20):1929-1940. [QxMD MEDLINE Link].
FDA approves first treatment for breast cancer with a certain inherited genetic mutation. U.S. Food & Drug Administration. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm592347.htm. January 12, 2018; Accessed: January 15, 2018.
Robson M, Im SA, Senkus E, Xu B, Domchek SM, Masuda N, et al. Olaparib for Metastatic Breast Cancer in Patients with a Germline BRCA Mutation. N Engl J Med. 2017 Aug 10. 377 (6):523-533. [QxMD MEDLINE Link].
Litton JK, Rugo HS, Ettl J, Hurvitz SA, Gonçalves A, Lee KH, et al. Talazoparib in Patients with Advanced Breast Cancer and a Germline BRCA Mutation. N Engl J Med. 2018 Aug 23. 379 (8):753-763. [QxMD MEDLINE Link].
Turner NC, Oliveira M, Howell SJ, and the, CAPItello-291 Study Group. Capivasertib in Hormone Receptor-Positive Advanced Breast Cancer. N Engl J Med. 2023 Jun 1. 388 (22):2058-2070. [QxMD MEDLINE Link].
[Guideline] Giordano SH, Franzoi MAB, Temin S, Anders CK, Chandarlapaty S, Crews JR, et al. Systemic Therapy for Advanced Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: ASCO Guideline Update. J Clin Oncol. 2022 Aug 10. 40 (23):2612-2635. [QxMD MEDLINE Link]. [Full Text].
Schmid P, et al, for the IMpassion130 Trial Investigators. Atezolizumab and Nab-Paclitaxel in Advanced Triple-Negative Breast Cancer. N Engl J Med. October 20, 2018. [Full Text].
Tecentriq (atezolizumab) [package insert]. South San Francisco, CA: Genentech, Inc. March 2019. Available at [Full Text].
FDA alerts health care professionals and oncology clinical investigators about efficacy and potential safety concerns with atezolizumab in combination with paclitaxel for treatment of breast cancer. U.S. Food & Drug Administration. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-health-care-professionals-and-oncology-clinical-investigators-about-efficacy-and. September 8, 2020; Accessed: September 23, 2020.
FDA grants regular approval to sacituzumab govitecan for triple-negative breast cancer. U.S. Food & Drug Administration. Available at https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-regular-approval-sacituzumab-govitecan-triple-negative-breast-cancer. April 7, 2021; Accessed: April 8, 2021.
Khan SA, Zhao F, Goldstein LJ, Cella D, Basik M, Golshan M, et al. Early Local Therapy for the Primary Site in De Novo Stage IV Breast Cancer: Results of a Randomized Clinical Trial (EA2108). J Clin Oncol. 2022 Mar 20. 40 (9):978-987. [QxMD MEDLINE Link]. [Full Text].
Goss PE, Ingle JN, Alés-Martínez JE, Cheung AM, Chlebowski RT, Wactawski-Wende J, et al. Exemestane for breast-cancer prevention in postmenopausal women. N Engl J Med. 2011 Jun 23. 364(25):2381-91. [QxMD MEDLINE Link]. [Full Text].
Cuzick J, Sestak I, Forbes JF, Dowsett M, Cawthorn S, Mansel RE, et al. Use of anastrozole for breast cancer prevention (IBIS-II): long-term results of a randomised controlled trial. Lancet. 2020 Jan 11. 395 (10218):117-122. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Visvanathan K, Fabian CJ, Bantug E, Brewster AM, Davidson NE, DeCensi A, et al. Use of Endocrine Therapy for Breast Cancer Risk Reduction: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2019 Nov 20. 37 (33):3152-3165. [QxMD MEDLINE Link]. [Full Text].
Surgery to Reduce the Risk of Breast Cancer. National Cancer Institute. Available at https://www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet. August 12, 2013; Accessed: April 6, 2017.
[Guideline] NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Risk Reduction. National Comprehensive Cancer Network. Available at https://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Version 1.2023 — October 12, 2022; Accessed: August 18, 2023.
Boughey JC, Attai DJ, Chen SL, Cody HS, Dietz JR, Feldman SM, et al. Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: Data on CPM Outcomes and Risks. Ann Surg Oncol. 2016 Oct. 23 (10):3100-5. [QxMD MEDLINE Link]. [Full Text].
Lancellotti P, Nkomo VT, Badano LP, Bergler J, Bogaert J, Davin L, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging. 2013 Aug. 14(8):721-40. [QxMD MEDLINE Link].
[Guideline] Greenlee H, Balneaves L, Carlson M, et al. Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer. J Natl Cancer Inst. 2014. 50:346-358. [Full Text].
Maia LO, Beaussant Y, Garcia ACM. The Therapeutic Potential of Psychedelic-assisted Therapies for Symptom Control in Patients Diagnosed With Serious Illness: A Systematic Review. J Pain Symptom Manage. 2022 Jun. 63 (6):e725-e738. [QxMD MEDLINE Link].
Lehto RH, Miller M, Sender J. The Role of Psilocybin-Assisted Psychotherapy to Support Patients With Cancer: A Critical Scoping Review of the Research. J Holist Nurs. 2022 Sep. 40 (3):265-280. [QxMD MEDLINE Link].
Olsson Möller U, Beck I, Rydén L, Malmström M. A comprehensive approach to rehabilitation interventions following breast cancer treatment - a systematic review of systematic reviews. BMC Cancer. 2019 May 20. 19 (1):472. [QxMD MEDLINE Link]. [Full Text].
Smith RA, Andrews KS, Brooks D, Fedewa SA, Manassaram-Baptiste D, Saslow D, et al. Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2019 May. 69 (3):184-210. [QxMD MEDLINE Link]. [Full Text].
Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007 Mar-Apr. 57 (2):75-89. [QxMD MEDLINE Link].
[Guideline] Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. Obstet Gynecol. 2017 Jul. 130 (1):e1-e16. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Schünemann HJ, Lerda D, Quinn C, et al, European Commission Initiative on Breast Cancer (ECIBC) Contributor Group. Breast Cancer Screening and Diagnosis: A Synopsis of the European Breast Guidelines. Ann Intern Med. 2019 Nov 26. [QxMD MEDLINE Link]. [Full Text].
Visvanathan K, Hurley P, Bantug E, Brown P, Col NF, Cuzick J, et al. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013 Aug 10. 31 (23):2942-62. [QxMD MEDLINE Link].
[Guideline] US Preventive Services Task Force., Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, et al. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2019 Sep 3. 322 (9):857-867. [QxMD MEDLINE Link].
[Guideline] Lyman GH, Somerfield MR, Bosserman LD, Perkins CL, Weaver DL, Giuliano AE. Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017 Feb 10. 35 (5):561-564. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Allison KH, Hammond MEH, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, et al. Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update. J Clin Oncol. 2020 Jan 13. JCO1902309. [QxMD MEDLINE Link].
[Guideline] Morrow M, Van Zee KJ, Solin LJ, Houssami N, Chavez-MacGregor M, Harris JR, et al. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma in Situ. Pract Radiat Oncol. 2016 Sep-Oct. 6 (5):287-95. [QxMD MEDLINE Link]. [Full Text].
Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014 Mar 1. 88 (3):553-64. [QxMD MEDLINE Link].
[Guideline] Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Practical Radiation Oncology. 2018. [Full Text].
[Guideline] Giordano SH, Temin S, Chandarlapaty S, Crews JR, Esteva FJ, Kirshner JJ, et al. Systemic Therapy for Patients With Advanced Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2018 Sep 10. 36 (26):2736-2740. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Burstein HJ, Lacchetti C, Anderson H, Buchholz TA, Davidson NE, Gelmon KE, et al. Adjuvant Endocrine Therapy for Women With Hormone Receptor-Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update on Ovarian Suppression. J Clin Oncol. 2016 May 10. 34 (14):1689-701. [QxMD MEDLINE Link]. [Full Text].
Burstein HJ, Temin S, Anderson H, Buchholz TA, Davidson NE, Gelmon KE, et al. Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: american society of clinical oncology clinical practice guideline focused update. J Clin Oncol. 2014 Jul 20. 32 (21):2255-69. [QxMD MEDLINE Link].
[Guideline] Harris LN, Ismaila N, McShane LM, Andre F, Collyar DE, Gonzalez-Angulo AM, et al. Use of Biomarkers to Guide Decisions on Adjuvant Systemic Therapy for Women With Early-Stage Invasive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016 Apr 1. 34 (10):1134-50. [QxMD MEDLINE Link].
[Guideline] Paluch-Shimon S, Pagani O, Partridge AH, Abulkhair O, Cardoso MJ, Dent RA, et al. ESO-ESMO 3rd international consensus guidelines for breast cancer in young women (BCY3). Breast. 2017 Oct. 35:203-217. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. CA Cancer J Clin. 2016 Jan-Feb. 66 (1):43-73. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Freedman RA, Minami CA, Winer EP, et al. Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol. 2021 Jan 28. [QxMD MEDLINE Link].
[Guideline] Cardoso F, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rubio IT, et al. Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2019 Aug 1. 30 (8):1194-1220. [QxMD MEDLINE Link]. [Full Text].
Tang G, Cuzick J, Costantino JP, Dowsett M, Forbes JF, Crager M, et al. Risk of recurrence and chemotherapy benefit for patients with node-negative, estrogen receptor-positive breast cancer: recurrence score alone and integrated with pathologic and clinical factors. J Clin Oncol. 2011 Nov 20. 29(33):4365-72. [QxMD MEDLINE Link]. [Full Text].
Chustecka Z. Novel Drug Approved for Breast Cancer: Palbociclib (Ibrance). Medscape Medical News. Available at http://www.medscape.com/viewarticle/839171. February 3, 2015; Accessed: April 6, 2017.
Finn RS, Crown JP, Lang I, Boer K, Bondarenko IM, Kulyk SO, et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1/TRIO-18): a randomised phase 2 study. Lancet Oncol. 2015 Jan. 16(1):25-35. [QxMD MEDLINE Link].
Ahearn TU, Zhang H, Michailidou K, et al. Common variants in breast cancer risk loci predispose to distinct tumor subtypes. Breast Cancer Res. 2022 Jan 4. 24 (1):2. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Anatomy of the breast.
Intrinsic subtypes of breast cancer.
Breast cancer. Intraductal carcinoma, comedo type. Distended duct with intact basement membrane and central tumor necrosis.
Breast cancer. Intraductal carcinoma, noncomedo type. Distended duct with intact basement membrane, micropapillary, and early cribriform growth pattern.
Breast cancer. Lobular carcinoma in situ. Enlargement and expansion of lobule with monotonous population of neoplastic cells.
Breast cancer. Lobular carcinoma in situ. Enlargement and expansion of lobule with monotonous population of neoplastic cells.
Breast cancer. Infiltrating ductal carcinoma. Low-grade carcinoma with well-developed glands invading fibrous stroma.
Breast cancer. Colloid (mucinous) carcinoma. Nests of tumor cells in pool of extracellular mucin.
Breast cancer. Papillary carcinoma. Solid papillary growth pattern with early cribriform and well-developed thin papillary fronds.
Anatomy of the breast. Courtesy of Wikimedia Commons (Patrick J Lynch, medical illustrator).

of 10

Author

Pavani Chalasani, MD, MPH Professor of Medicine, Director, Division of Hematology and Oncology, Leader, Breast Cancer Clinical Research Team, Co-Program Leader, Clinical and Translational Oncology Program, George Washington Cancer Center, George Washington University School of Medicine and Health Sciences

Pavani Chalasani, MD, MPH is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Hemostasis and Thrombosis Research Society, SWOG

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Bayer, Heron, Amgen, Athenex, Novartis, Eisai, Eli Lilly, Zentalis <br/>Received research grant from: Pfizer.

Coauthor(s)

Abigail Camenisch, BS, MPH MD Candidate, University of Arizona College of Medicine

Disclosure: Nothing to disclose.

Chief Editor

John V Kiluk, MD, FACS Associate Professor, Department of Oncologic Sciences, Department of Surgery (Joint Appointment), University of South Florida Morsani College of Medicine; Clinical Director, Breast Surgical Oncology, Associate Member, Comprehensive Breast Program, Department of Women's Oncology, H Lee Moffitt Cancer Center and Research Institute

John V Kiluk, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, Moretz Surgical Society, Society of Surgical Oncology, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Alison T Stopeck, MD Professor of Medicine, Arizona Cancer Center, University of Arizona Health Sciences Center; Director of Clinical Breast Cancer Program, Arizona Cancer Center; Medical Director of Coagulation Laboratory, University Medical Center; Director of Arizona Hemophilia and Thrombosis Center

Alison T Stopeck, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, SWOG, American Society of Clinical Oncology, Hemophilia and Thrombosis Research Society

Disclosure: Received honoraria from Genentech for speaking and teaching; Received honoraria from AstraZeneca for speaking and teaching; Received grant/research funds from AstraZeneca for other.

Patricia A Thompson, PhD Assistant Professor, Department of Pathology, University of Arizona College of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Leona Downey, MD Assistant Professor of Internal Medicine, Section of Oncology and Hematology, University of Arizona, Arizona Cancer Center

Leona Downey, MD is a member of the following medical societies: American Geriatrics Society, American Society of Clinical Oncology, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Manjit Singh Gohel, MD, MRCS, MB, ChB Specialist Registrar, Division of Breast and Endocrine Surgery, Northwick Park Hospital

Disclosure: Nothing to disclose.

Harold Harvey, MD Professor, Department of Medicine, Pennsylvania State University

Disclosure: Nothing to disclose.

Kanchan Kaur, MBBS, MS (General Surgery), MRCS (Ed) Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India

Disclosure: Nothing to disclose.

Julie Lang, MD Assistant Professor of Surgery and the BIO5 Institute, Director of Breast Surgical Oncology, University of Arizona College of Medicine

Julie Lang, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Clinical Oncology, Association for Academic Surgery, and Society of Surgical Oncology

Disclosure: Genomic Health Grant/research funds Speaking and teaching; Agendia Grant/research funds Speaking and teaching; Surgical Tools Grant/research funds Research; Sysmex Grant/research funds Research

Robert B Livingston, MD Professor of Clinical Medicine and Director, Clinical Research Shared Services, Arizona Cancer Center

Robert B Livingston, MD is a member of the following medical societies: American Association for Cancer Research, American Federation for Clinical Research, and American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Hanan Makhoul, MD Staff Physician, Department of Internal Medicine, University of Arkansas School of Medicine

Disclosure: Nothing to disclose.

Issam Makhoul, MD Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences

Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology

Disclosure: Nothing to disclose.

Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International

Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy

Disclosure: Nothing to disclose.

Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) Senior Lecturer, Director of Breast Service, Department of Surgery, Imperial College School of Medicine; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK

Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Wiley Souba, MD Chairman, Professor, Department of General Surgery, Pennsylvania State College of Medicine; Chief Surgeon, The Milton S Hershey Medical Center

Disclosure: Nothing to disclose.

Rachel Swart, MD, PhD Assistant Professor of Medicine, Department of Hematology and Oncology, Arizona Cancer Center, University of Arizona

Rachel Swart, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, Arizona Medical Association, and Southwest Oncology Group

Disclosure: Roche Grant/research funds Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Simon Thomson, MB, BCh, MD, FRCS Specialist Registrar, Department of Breast and Endocrine Surgery, Northwick Park Hospital, UK

Simon Thomson, MB, BCh, MD, FRCS is a member of the following medical societies: British Medical Association

Disclosure: Nothing to disclose.

Modality	Sensitivity	Specificity	PPV	Indications
Mammography	63-95% (>95% palpable, 50% impalpable, 83-92% in women older than 50 y; decreases to 35% in dense breasts)	14-90% (90% palpable)	10-50% (94% palpable)	Initial investigation for symptomatic breast in women older than 35 y and for screening; investigation of choice for microcalcification
Ultrasonography	68-97% palpable	74-94% palpable	92% (palpable)	Initial investigation for palpable lesions in women younger than 35 y
MRI	86-100%	21-97% (< 40% primary cancer)	52%	Scarred breast, implants, multifocal lesions, and borderline lesions for breast conservation; may be useful in screening high-risk women
Scintigraphy	76-95% palpable, 52-91% impalpable	62-94% (94% impalpable)	70-83% (83% palpable, 79% impalpable)	Lesions >1 cm and axilla assessment; may help predict drug resistance
PET	96% (90% axillary metastases)	100%		Axilla assessment, scarred breast, and multifocal lesions
MRI = magnetic resonance imaging; PET = positron emission tomography; PPV = positive predictive value.

	Score
	1	> 2	> 3
A. Tubule formation	>75%	10-75%	< 10%
B. Mitotic count/HPF (microscope- and field-dependent)	< 7	7-12	>12
C. Nuclear size and pleomorphism	Near normal; little variation	Slightly enlarged; moderate variation	Markedly enlarged; marked variation
Grade I cancer if total score (A + B + C) is 3-5
Grade II cancer if total score (A + B + C) is 6 or 7
Grade III cancer if total score (A + B + C) is 8 or 9
HPF = high-power field.

DCIS Characteristic	Comedo	Noncomedo
Nuclear grade	High	Low
Estrogen receptor	Often negative	Positive
Distribution	Continuous	Multifocal
Necrosis	Present	Absent
Local recurrence	High	Low
Prognosis	Worse	Better
DCIS = ductal carcinoma in situ.

Primary tumor (T)
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ
Tis (DCIS)	Ductal carcinoma in situ
Tis (Paget)	Paget disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are categorized on the basis of the size and characteristics of the parenchymal disease, although the presence of Paget disease should still be noted
T1	Tumor ≤ 20 mm in greatest dimension
T1mi	Tumor ≤ 1 mm in greatest dimension
T1a	Tumor > 1 mm but ≤ 5 mm in greatest dimension (round any measurement >1.0-1.9 mm to 2 mm)
T1b	Tumor > 5 mm but ≤ 10 mm in greatest dimension
T1c	Tumor > 10 mm but ≤ 20 mm in greatest dimension
T2	Tumor > 20 mm but ≤ 50 mm in greatest dimension
T3	Tumor > 50 mm in greatest dimension
T4	Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules), not including invasion of dermis alone
T4a	Extension to chest wall, not including only pectoralis muscle adherence/invasion
T4b	Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d’orange) of the skin, which do not meet the criteria for inflammatory carcinoma
T4c	Both T4a and T4b
T4d	Inflammatory carcinoma
Regional lymph nodes (N)
Clinical
cNX	Regional lymph nodes cannot be assessed (eg, previously removed)
cN0	No regional lymph node metastasis (on imaging or clinical examination)
cN1	Metastasis to movable ipsilateral level I, II axillary lymph node(s)
cN1mi	Micrometastases (approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)
cN2	Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases
cN2a	Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures
cN2b	Metastases only in ipsilateral internal mammary nodes and in the absence of axillary lymph node metastases
cN3	Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s), with or without level I, II axillary node involvement, or in ipsilateral internal mammary lymph node(s) with level I, II axillary lymph node metastasis; or metastases in ipsilateral supraclavicular lymph node(s), with or without axillary or internal mammary lymph node involvement
cN3a	Metastasis in ipsilateral infraclavicular lymph node(s)
cN3b	Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
cN3c	Metastasis in ipsilateral supraclavicular lymph node(s)
Note: (sn) and (f) suffixes should be added to the N category to denote confirmation of metastasis by sentinel node biopsy or fine needle aspiration/core needle biopsy, respectively.
Pathologic (pN)
pNX	Regional lymph nodes cannot be assessed (for example, previously removed, or not removed for pathologic study)
pN0	No regional lymph node metastasis identified histologically, or isolated tumor cell clusters (ITCs) only. Note: ITCs are defined as small clusters of cells ≤ 0.2 mm, or single tumor cells, or a cluster of < 200 cells in a single histologic cross-section; ITCs may be detected by routine histology or by immunohistochemical (IHC) methods; nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should be included in the total number of nodes evaluated
pN0(i)	No regional lymph node metastases histologically, negative IHC
pN0(i+)	ITCs only in regional lymph node(s)
pN0(mol-)	No regional lymph node metastases histologically, negative molecular findings (reverse transcriptase polymerase chain reaction [RT-PCR])
pN0(mol+)	Positive molecular findings by RT-PCR; no ITCs detected
pN1	Micrometastases; or metastases in 1-3 axillary lymph nodes and/or in internal mammary nodes; and/or in clinically negative internal mammary nodes with micrometastases or macrometastases by sentinel lymph node biopsy
pN1mi	Micrometastases (200 cells, > 0.2 mm but none > 2.0 mm)
pN1a	Metastases in 1-3 axillary lymph nodes (at least 1 metastasis > 2.0 mm)
pN1b	Metastases in ipsilateral internal mammary lymph nodes, excluding ITCs, detected by sentinel lymph node biopsy
pN1c	Metastases in 1-3 axillary lymph nodes and in internal mammary sentinel nodes (ie, pN1a and pN1b combined)
pN2	Metastases in 4-9 axillary lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the absence of axillary lymph node metastases
pN2a	Metastases in 4-9 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)
pN2b	Clinically detected* metastases in internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary lymph nodes
pN3	Metastases in ≥ 10 axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the presence of one or more positive level I, II axillary lymph nodes; or in > 3 axillary lymph nodes and micrometastases or macrometastases by sentinel lymph node biopsy in clinically negative ipsilateral internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes
pN3a	Metastases in ≥ 10 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes
pN3b	pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging) or pN2a in the presence of pN1b
pN3c	Metastases in ipsilateral supraclavicular lymph nodes
*"Clinically detected" is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis on the basis of FNA biopsy with cytologic examination.
Distant metastasis (M)
M0	No clinical or radiographic evidence of distant metastasis
cM0(i+)	No clinical or radiographic evidence of distant metastases in the presence of tumor cells or deposits no larger than 0.2 mm detected microscopically or by molecular techniques in circulating blood, bone marrow, or other nonregional nodal tissue in a patient without symptoms or signs of metastase
cM1	Distant metastases detected by clinical and radiographic means
pM1	Any histologically proven metastases in distant organs; or if in non-regional nodes, metastases > 0.2 mm

Histologic grade (G)
GX	Grade cannot be assessed
G1	Low combined histologic grade (favorable)
G2	Intermediate combined histologic grade (moderately favorable)
G3	High combined histologic grade (unfavorable)

Stage	T	N	M
0	Tis	N0	M0
IA	T1	N0	M0
IB	T0	N1mi	M0
	T1	N1mi	M0
IIA	T0	N1	M0
	T1	N1	M0
	T2	N0	M0
IIB	T2	N1	M0
	T3	N0	M0
IIIA	T0	N2	M0
	T1	N2	M0
	T2	N2	M0
	T3	N1	M0
	T3	N2	M0
IIIB	T4	N0	M0
	T4	N1	M0
	T4	N2	M0
IIIC	Any T	N3	M0
IV	Any T	Any N	M1

TNM	Grade	HER2	ER	PR	Stage
Tis N0 M0	Any	Any	Any	Any	0
T1 N0 M0 T0 N1mi M0 T1 N1mi M0	G1	Positive	Positive	Positive	IA
				Negative
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative
			Negative	Positive
				Negative	IB
	G2	Positive	Positive	Positive	IA
				Negative
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative
			Negative	Positive
				Negative	IB
	G3	Positive	Positive	Positive	IA
				Negative
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative	IB
			Negative	Positive
				Negative
T0 N1 M0 T1 N1 M0 T2 N0 M0	G1	Positive	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative
		Negative	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative
	G2	Positive	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative
		Negative	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative	IIB
	G3	Positive	Positive	Positive	IB IIA
				Negative
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative	IIB
			Negative	Positive
				Negative
T2 N1 M0 T3 N0 M0	G1	Positive	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative	IIB
		Negative	Positive	Positive	IIA
				Negative	IIB
			Negative	Positive
				Negative
	G2	Positive	Positive	Positive	IB
				Negative	IIA
			Negative	Positive
				Negative	IIB
		Negative	Positive	Positive	IIA
				Negative	IIB
			Negative	Positive
				Negative	IIIB
	G3	Positive	Positive	Positive	IB
				Negative	IIB
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative	IIIA
			Negative	Positive
				Negative	IIIB
T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1 M0 T3 N2 M0	G1	Positive	Positive	Positive	IIA
				Negative	IIIA
			Negative	Positive
				Negative
		Negative	Positive	Positive	IIA
				Negative	IIIA
			Negative	Positive
				Negative	IIIB
	G2	Positive	Positive	Positive	IIA
				Negative	IIIA
			Negative	Positive
				Negative
		Negative	Positive	Positive	IIA
				Negative	IIIA
			Negative	Positive
				Negative	IIIB
	G3	Positive	Positive	Positive	IIB
				Negative	IIIA
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative	IIIB
			Negative	Positive
				Negative	IIIC
T4 N0 M0 T4 N1 M0 T4 N2 M0 Any T N3 M0	G1	Positive	Positive	Positive	IIIA
				Negative	IIIB
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative
			Negative	Positive
				Negative	IIIC
	G2	Positive	Positive	Positive	IIIA
				Negative	IIIB
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative
			Negative	Positive
				Negative	IIIC
	G3	Positive	Positive	Positive	IIIB
				Negative
			Negative	Positive
				Negative
		Negative	Positive	Positive
				Negative	IIIC
			Negative	Positive
				Negative
Any T Any N M1	Any	Any	Any	Any	IV
ER=estrogen receptor; PR=progesterone receptor

Agent	Dose and Schedule
Postmenopausal
Tamoxifen	20 mg PO every day
Elacestrant	345 mg PO every day
Or
Aromatase inhibitor
Anastrozole	1 mg PO every day
Letrozole	2.5 mg PO every day
Exemestane	25 mg PO every day
Or
Fulvestrant	500 mg IM on days 1, 15, 29, and once monthly thereafter
Or
Megestrol	40 mg PO 4 times a day
Premenopausal
Tamoxifen	20 mg PO every day
Or
Aromatase inhibitor + LHRH*
Leuprolide	7.5 mg IM depot q28d 22.5 mg IM q3mo 30 mg IM q4mo
Goserelin	3.6 mg SC depot q28d 10.8 mg SC q3mo
Megestrol	40 mg PO 4 times a day
*LHRH = luteinizing hormone–releasing hormone.

Drug	Class	Dose/Schedule	Overall Response Rate (ORR)	Toxicity
Abemaciclib	CDK inhibitor	200 mg PO BID continue until disease progression	19.7%	Diarrhea, fatigue, neutropenia and nausea
Alpelisib	PI3K inhibitor	300 mg PO qDay continue until disease progression	26.6%	Hypersensitivity, diarrhea, cutaneous adverse reactions, hyperglycemia
Capecitabine	Oral fluoro-pyrimidine	1250 mg/m²/d PO for 2 weeks with 1 wk off	30%	Rash, hand-foot syndrome, diarrhea, mucositis
Docetaxel	Antimicrotubule	75-100 mg/m² IV q3wk or 40 mg/m²/wk X IV for 6 wk with 2 wk off	30-68%	Myelosuppression, alopecia, skin reaction, mucositis, and fluid retention
Doxorubicin	Anthracycline (antitumor antibiotic)	45-60 mg/m² IV q3wk or 20 mg/m² IV qwk (not to exceed a cumulative dose of 450-500 mg/m²)	35-50%	Myelosuppression, nausea/ vomiting, mucositis, diarrhea cardiotoxicity, alopecia
Doxil (liposomal encapsulated doxorubicin)	Anthracycline	20 mg/m² IV q2wk or 35-40 mg/m² IV q4wk		Less cardiotoxicity, neutropenia, alopecia, stomatitis, hand-foot syndrome
Epirubicin	Anthracycline	90 mg/m² IV q3wk (not to exceed cumulative dose of 900 mg/m²)	35-50%	Myelosuppression, mucositis, nausea, vomiting, cardiotoxicity
Everolimus	mTor kinase inhibitor	10 mg PO qDay continue until disease progression	12.6%	Stomatitis, constipation, infection, asthenia, fatigue, cough
Gemcitabine	Antimetabolite	725 mg/m²/wk IV for 3 wk then 1 wk off or 1 g/m²/wk IV X 2 then 1 wk off		Myelosuppression, nausea/ vomiting, flulike syndrome, elevated LFTs
Nab-paclitaxel	Antimicrotubule	80-100 mg/m²/wk IV X 3 then 1 wk off or 260 mg/m² IV q3wk	58-62% 33%	Less neuropathy, and allergic reaction
Olaparib	PARP inhibitor	300 mg PO BID	59.9%	Anemia, fatigue, nausea, and vomiting
Paclitaxel	Antimicrotubule	80 mg/m²/wk IV or 175 mg/m² IV over 3 hours q3wk	25-50%	Myelosuppression, alopecia, neuropathy, allergic reaction
Pertuzumab	Monoclonal antibody	840 mg IV loading dose, then 420 mg q3wk Give with trastuzumab and docetaxel	80.2% (objective response rate)	Fever, allergic reaction, cardiotoxicity/congestive heart failure
Palbociclib	CDK inhibitor	125 mg/day PO for 3 weeks with 1 wk off Give with letrozole	Data are not available for ORR Mean PFS was 10.2 months in the letrozole group and 20.2 months for palbociclib plus letrozole group	Neutropenia, leukopenia, thrombocytopenia, anemia, stomatitis
Ribociclib	CDK inhibitor	600 mg/day PO for 3 weeks with 1 wk off Give with letrozole	Mean PFS was 16 months in the letrozole group and 25.3 months for ribociclib	QT prolongation, hepatobiliary toxicity, neutropenia, alopecia, diarrhea, vomiting, constipation, fatigue, anorexia
Sacituzumab govitecan	Monoclonal antibody	10 mg/kg IV on Days 1 and 8 with 2 wk off	33.3%	Nausea, neutropenia, diarrhea, fatigue, anemia, vomiting
Talazoparib	PARP inhibitor	1 mg PO qDay	62.6%	Fatigue, anemia, nausea, neutropenia, headache, thrombocytopenia, vomiting, alopecia, diarrhea, and decreased appetite
Trastuzumab or biosimilars of trastuzumab	Monoclonal antibody	Combination therapy: 4 mg/kg IV once, then 2 mg/kg weekly for 12-18 weeks, then 6 mg/kg q3weeks to total 52 weeks Single agent: 8 mg/kg IV once, then 6 mg/kg q3weeks to total 52 weeks	10-15%	Fever, allergic reaction, cardiotoxicity/congestive heart failure
Trastuzumab deruxtecan^[179]	Monoclonal antibody conjugate	5.4 mg/kg IV q3weeks	60.3%	Interstitial lung disease and pneumonitis; neutropenia; left ventricular dysfunction
Tucatinib^[180]	Tyrosine kinase inhibitor of HER2	300 mg PO BID	40.6%	Diarrhea, hand-foot syndrome, nausea, fatigue, hepatotoxicity
Vinorelbine	Vinca alkaloid	20 mg/m²/wk IV	35-45%	Myelosuppression, nausea/ vomiting, constipation, fatigue, stomatitis, anorexia

	NCCN	ASCO
History and physical examination	Year 1, every 3-4 mo Year 2, every 4 mo Year 3-5, every 6 mo Year 6+, annually	Year 1-3, every 3-6 mo Year 4-5, every 6-12 mo Year 6+, annually
Breast self-examination	No recommendation	Counseled to perform monthly breast self-examination
Mammography	6 mo after post-BCS radiation therapy Annually thereafter	6 mo after definitive radiation therapy Every 6-12 mo for surveillance of abnormalities Annually if stability of abnormalities is achieved
Pelvic examination	Annually, for women on tamoxifen Annual exam if uterus present	Regular gynecologic follow-up Patients on tamoxifen should be advised to report any vaginal bleeding
Routine blood tests	Not recommended	Not recommended
Imaging studies	Not recommended	Not recommended
Tumor marker testing	Not recommended	Not recommended

Breast Cancer Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

What would you like to print?