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onc.breast-cancer.core.v1

Breast cancer (core)

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Breast cancer (core) dossier. Spans screening (USPSTF 2024 biennial 40-74), diagnostic triple-assessment (BI-RADS), receptor profiling (ER/PR/HER2 IHC+FISH), AJCC 8th edition staging, and 7-axis subtype-stratified regimen (HR+/HER2- endocrine + abemaciclib monarchE, HER2+ TCHP + KATHERINE T-DM1, TNBC KEYNOTE-522 pembro+chemo, metastatic HR+/HER2- CDK4/6, metastatic HER2+ T-DXd DESTINY-Breast03, metastatic TNBC ASCENT sacituzumab, germline-BRCA OlympiA olaparib). All antineoplastic RxCUIs RxNav-verified 2026-05-26 (tamoxifen 10324, anastrozole 84857, letrozole 72965, exemestane 258494, fulvestrant 282357, abemaciclib 1946825, palbociclib 1601374, ribociclib 1873916, trastuzumab 224905, pertuzumab 1298944, T-DM1 1371041, T-DXd 2267582, sacituzumab govitecan 2360232, pembrolizumab 1547545, olaparib 1597582, talazoparib 2099704, paclitaxel 56946, docetaxel 72962, doxorubicin 3639, cyclophosphamide 3002, carboplatin 40048, capecitabine 194000, elacestrant 2628469, tucatinib 2361285). All PMIDs PubMed-MCP live-verified 2026-05-26 — three prompt-candidate PMIDs dropped as wrong-article (34534430 = T-DXd MUTANT lung NSCLC; 34038159 = gut microbiome; 30586810 = environmental toxicology).

Entry points (5)

  • imaging
    Screen-detected or diagnostic mammographic abnormality BI-RADS 4-5 (NCCN Breast 2026)
    mammographic_abnormality_bi_rads_4_5
  • symptom
    Palpable breast mass, nipple discharge (bloody/unilateral), or skin change (NCCN Breast 2026)
    palpable_breast_mass
  • problem_list
    Biopsy-confirmed invasive breast cancer or DCIS (NCCN Breast 2026)
    confirmed_breast_cancer
  • demographic
    Age 40-74 for biennial screening mammography (USPSTF 2024 Grade B)
    usptf_screening_age
  • history
    Germline BRCA1/2 carrier, Lynch, Li-Fraumeni, or Tyrer-Cuzick lifetime risk >=20% (NCCN germline 2024)
    germline_brca_or_high_familial_risk

Required inputs (16)

  • agerequired
    demographic • used at FRAME
    Screening eligibility (USPSTF 2024), menopausal status assumptions, dose adjustment, comorbidity burden
  • menopausal_statusrequired
    history • used at CONTEXT
    Drives endocrine-therapy choice (tamoxifen vs AI), ovarian-suppression decision (SOFT/TEXT)
  • family_history_breast_ovarianrequired
    history • used at CONTEXT
    Tyrer-Cuzick risk assessment, BRCA testing criteria (NCCN germline 2024)
  • ecog_psrequired
    history • used at CONTEXT
    Performance status drives treatment eligibility, especially for cytotoxic/intensive regimens
  • weightrequired
    vital • used at CONTEXT
    BSA for chemotherapy dosing (Mosteller preferred)
  • heightrequired
    vital • used at CONTEXT
    BSA computation
  • mammography_usrequired
    imaging • used at INITIAL_WORKUP
    Diagnostic mammography + targeted breast US for BI-RADS lesions; baseline staging
  • breast_biopsy_corerequired
    imaging • used at INITIAL_WORKUP
    Image-guided core biopsy for BI-RADS 4-5; provides histology + receptor status
  • er_pr_her2_statusrequired
    lab • used at BRANCHING_WORKUP
    ER + PR + HER2 (IHC ± FISH if 2+) define subtype and therapy axis selection
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline before chemotherapy; cytopenias affect dose intensity (NCCN Breast 2026)
  • lftrequired
    lab • used at INITIAL_WORKUP
    Hepatic function for chemo + endocrine therapy dosing + irAE monitoring
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal function for carboplatin AUC, contrast staging, anti-HER2 dosing
  • lvef_baseline_echo_muga
    imaging • used at INITIAL_WORKUP
    Baseline LVEF before anthracycline/trastuzumab; on-treatment surveillance q3 mo on anti-HER2
  • germline_brca_panel
    lab • used at BRANCHING_WORKUP
    Germline panel per NCCN criteria; drives olaparib eligibility (OlympiA) + risk-reducing surgery counseling
  • oncotype_dx_or_mammaprint
    lab • used at RISK_STRATIFICATION
    21-gene recurrence score (Oncotype) drives adjuvant chemo decision in HR+/HER2- (TAILORx)
  • pik3ca_esr1_circulating_tumor_dna
    lab • used at BRANCHING_WORKUP
    Metastatic HR+/HER2- progressed disease — PIK3CA (alpelisib) and ESR1 (elacestrant) genotyping

12-phase flow (12)

  1. 1FRAME
    Determine scope: screening vs symptomatic workup vs confirmed disease; capture menopausal status and family-history axis for downstream genetic testing decisions (NCCN Breast 2026)
    inputs: age, menopausal_status
    advance: Clinical scope identified (screening, diagnostic workup, or confirmed disease) with menopausal axis (NCCN Breast 2026)
  2. 2ENTRY
    Capture trigger: screening-eligible age, mammographic abnormality BI-RADS 4-5, palpable mass, known biopsy diagnosis, or high-risk family history (NCCN Breast 2026)
    inputs: age
    actions: workup.breast_screening_mammogram
    advance: Entry trigger documented; if biopsy-positive route to staging workup (NCCN Breast 2026)
  3. 3CONTEXT
    ECOG, comorbidities (cardiac for anti-HER2 / anthracycline), prior chest RT (cardiotoxicity risk), pregnancy status, fertility preservation goals, baseline weight + BSA, family history with Tyrer-Cuzick scoring (NCCN Breast 2026)
    inputs: ecog_ps, weight, height, family_history_breast_ovarian
    actions: calc.bsa, calc.tyrer_cuzick
    advance: Performance + comorbidity + risk profile established (NCCN Breast 2026)
  4. 4RED_FLAGS
    Inflammatory breast cancer (peau d-orange + erythema), spinal cord compression from bone metastases, hypercalcaemia of malignancy, malignant pericardial or pleural effusion, brain metastases with neurologic deficit (NCCN Breast 2026)
    advance: Oncologic emergencies screened; emergent intervention triggered if positive (NCCN Breast 2026)
  5. 5INITIAL_WORKUP
    Diagnostic mammography + targeted breast US for BI-RADS lesions, image-guided core biopsy (workup.breast_biopsy), baseline CBC + CMP + LFTs, baseline echo or MUGA if anti-HER2 / anthracycline planned (NCCN Breast 2026)
    inputs: mammography_us, breast_biopsy_core, cbc, lft, creatinine
    actions: workup.breast_biopsy, panel.cbc, panel.lft, panel.renal
    advance: Histology confirmed; baseline labs + LVEF (if applicable) documented (NCCN Breast 2026)
  6. 6BRANCHING_WORKUP
    Receptor profiling (ER/PR/HER2 IHC + FISH), Ki-67; Oncotype DX or MammaPrint for early HR+/HER2- node-negative; germline BRCA panel per NCCN criteria; staging imaging (CT chest/abdomen/pelvis + bone scan) for clinical stage III+ or biomarker-driven; PIK3CA + ESR1 cell-free DNA at metastatic progression (NCCN Breast 2026)
    inputs: er_pr_her2_status
    actions: workup.genetic_counseling
    advance: Subtype, recurrence-risk score (if applicable), and germline status documented (NCCN Breast 2026)
  7. 7DIFFERENTIAL
    DCIS vs invasive ductal vs invasive lobular vs special histologies (mucinous, tubular, metaplastic, papillary); contralateral disease vs metastasis; rule out lymphoma, sarcoma in unusual presentations (NCCN Breast 2026)
    advance: Histologic subtype + invasion status defined (NCCN Breast 2026)
  8. 8RISK_STRATIFICATION
    AJCC 8th-edition anatomic + prognostic stage (TNM + receptor/grade), Oncotype recurrence score / MammaPrint for adjuvant chemo decision, Tyrer-Cuzick / Gail risk for chemoprevention, baseline LVEF for cardiotoxicity risk (NCCN Breast 2026)
    inputs: oncotype_dx_or_mammaprint
    actions: calc.tyrer_cuzick, calc.gail_model
    advance: Stage assigned; adjuvant-chemotherapy gate cleared via recurrence score (NCCN Breast 2026)
  9. 9TREATMENT
    Subtype + stage-stratified plan: HR+/HER2- (surgery + adjuvant endocrine ± abemaciclib for high-risk N+); HER2+ (neoadjuvant TCHP + adjuvant T-DM1 for residual or trastuzumab 1 yr if pCR); TNBC (neoadjuvant pembro + chemo per KEYNOTE-522); metastatic per axis (CDK4/6, T-DXd, sacituzumab govitecan, alpelisib, elacestrant); germline-BRCA adjuvant olaparib per OlympiA (NCCN Breast 2026)
    inputs: creatinine, lft, ecog_ps, er_pr_her2_status
    advance: Subtype-matched regimen selected with cardiac + irAE safety reviewed (NCCN Breast 2026)
  10. 10DISPOSITION
    Outpatient infusion centre for systemic therapy; inpatient for surgical resection (lumpectomy/mastectomy with SLNB/ALND), neutropenic fever, severe irAE, oncologic emergency; transition to palliative team when goals shift (NCCN Breast 2026)
    advance: Care setting and treatment timeline established (NCCN Breast 2026)
  11. 11MONITORING
    Echo q3 mo on anti-HER2 (cardiotoxicity); CBC + LFT before each cycle; q2-4 wk TSH + LFT + glucose on pembrolizumab (irAE); bone density on AI (q2 yr); endocrine-therapy adherence checks; symptom monitoring for recurrence (NCCN Breast 2026)
    inputs: lvef_baseline_echo_muga, lft, cbc
    actions: panel.cbc, panel.lft, panel.cardiac
    advance: Surveillance schedule documented with cardiac + irAE + bone-density bands (NCCN Breast 2026)
  12. 12FOLLOWUP
    NCCN survivorship intervals: H&P q3-6 mo x 5 yr then annual; annual mammogram; 5-10 yr endocrine therapy adherence; fertility preservation conversation if premenopausal at diagnosis; sexuality + lymphedema + psychosocial support; genetic counseling for cascade testing if BRCA+ (NCCN Breast 2026)
    advance: Survivorship plan documented with next scan + endocrine duration + cascade-testing plan (NCCN Breast 2026)