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onc.breast-cancer.core.v1PRODUCTION
onc.breast-cancer.core.v1

Breast cancer (core)

oncologychronicadultgeriatricpregnancy
Hard-required inputs
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
2
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Advance rule
Set
Advance when

Clinical scope identified (screening, diagnostic workup, or confirmed disease) with menopausal axis (NCCN Breast 2026)

Patient inputs (16)

ER + PR + HER2 (IHC ± FISH if 2+) define subtype and therapy axis selection

Drives endocrine-therapy choice (tamoxifen vs AI), ovarian-suppression decision (SOFT/TEXT)

Tyrer-Cuzick risk assessment, BRCA testing criteria (NCCN germline 2024)

Performance status drives treatment eligibility, especially for cytotoxic/intensive regimens

BSA for chemotherapy dosing (Mosteller preferred)

BSA computation

Screening eligibility (USPSTF 2024), menopausal status assumptions, dose adjustment, comorbidity burden

Diagnostic mammography + targeted breast US for BI-RADS lesions; baseline staging

Image-guided core biopsy for BI-RADS 4-5; provides histology + receptor status

Baseline before chemotherapy; cytopenias affect dose intensity (NCCN Breast 2026)

Hepatic function for chemo + endocrine therapy dosing + irAE monitoring

Renal function for carboplatin AUC, contrast staging, anti-HER2 dosing

Germline panel per NCCN criteria; drives olaparib eligibility (OlympiA) + risk-reducing surgery counseling

Metastatic HR+/HER2- progressed disease — PIK3CA (alpelisib) and ESR1 (elacestrant) genotyping

Baseline LVEF before anthracycline/trastuzumab; on-treatment surveillance q3 mo on anti-HER2

21-gene recurrence score (Oncotype) drives adjuvant chemo decision in HR+/HER2- (TAILORx)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningmalignant_spinal_cord_compression_bone_mets
    Bone metastases with new back pain + neurologic deficit (motor weakness, sensory level, bladder/bowel) — MRI within hours
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinflammatory_breast_cancer_presentation
    Erythema, peau d-orange, rapidly progressive skin change with biopsy showing dermal lymphatic invasion (T4d) — inflammatory breast cancer (IBC)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypercalcaemia_of_malignancy
    Corrected Ca >12 mg/dL with metastatic breast cancer — symptomatic (confusion, AKI, arrhythmia)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretrastuzumab_lvef_drop_or_clinical_hf
    LVEF drop >=10% to <50% on anti-HER2, or symptomatic HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_irae_on_pembrolizumab
    Grade >=3 immune-related toxicity on pembrolizumab (pneumonitis, hepatitis, colitis, myocarditis, endocrinopathy with hospitalization, severe skin)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

CONTEXToptionalDrives risk stratification
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Recommended regimen

HR+/HER2- adjuvant endocrine therapy ladder
axis: breast_hrpos_her2neg_adjuvant_endocrine
Selected axis "HR+/HER2- adjuvant endocrine therapy ladder" by default fallback (first axis)
  • tamoxifen
    first line
    SERM
    20 mg • PO • once daily x 5-10 years
    triggers: premenopausal_low_to_intermediate_risk
    Premenopausal HR+ adjuvant standard; 10-year duration improves OS in higher-risk (ATLAS); also acceptable postmenopausal if AI intolerance
    rxcui 10324
  • anastrozole
    first line
    aromatase_inhibitor
    1 mg • PO • once daily x 5 years
    triggers: postmenopausal_or_ovarian_suppressed
    Postmenopausal HR+ adjuvant first-line; superior to tamoxifen for DFS (ATAC); recommend bone-density surveillance
    rxcui 84857
  • letrozole
    first line
    aromatase_inhibitor
    2.5 mg • PO • once daily x 5 years
    triggers: postmenopausal_or_ovarian_suppressed_alternative_ai
    Alternative postmenopausal AI; equally efficacious to anastrozole (BIG 1-98)
    rxcui 72965
  • exemestane
    second line
    aromatase_inhibitor
    25 mg • PO • once daily
    triggers: postmenopausal_ai_switch_for_intolerance
    Steroidal AI option; switch strategy after 2-3 yr tamoxifen (TEAM)
    rxcui 258494
  • abemaciclib
    add on
    CDK4_6_inhibitor
    150 mg • PO • BID x 2 years
    triggers: high_risk_node_positive_hr_pos_her2_neg
    monarchE (Johnston JCO 2020 PMID 32954927) — 2-year adjuvant abemaciclib + ET improves iDFS in node-positive high-risk HR+/HER2- early breast cancer
    rxcui 1946825

Auto-drafted A&P note

Subjective

- Possible entry pathways: Screen-detected or diagnostic mammographic abnormality BI-RADS 4-5 (NCCN Breast 2026); Palpable breast mass, nipple discharge (bloody/unilateral), or skin change (NCCN Breast 2026); Biopsy-confirmed invasive breast cancer or DCIS (NCCN Breast 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Breast cancer (core)** (onc.breast-cancer.core.v1).
Phenotype framing: 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)
Scope: Determine scope: screening vs symptomatic workup vs confirmed disease; capture menopausal status and family-history axis for downstream genetic testing decisions (NCCN Breast 2026)

No severity triggers fired against current inputs.

Plan

Regimen axis: **HR+/HER2- adjuvant endocrine therapy ladder**.
1. tamoxifen 20 mg PO once daily x 5-10 years (SERM, first line) — Premenopausal HR+ adjuvant standard; 10-year duration improves OS in higher-risk (ATLAS); also acceptable postmenopausal if AI intolerance
2. anastrozole 1 mg PO once daily x 5 years (aromatase_inhibitor, first line) — Postmenopausal HR+ adjuvant first-line; superior to tamoxifen for DFS (ATAC); recommend bone-density surveillance
3. letrozole 2.5 mg PO once daily x 5 years (aromatase_inhibitor, first line) — Alternative postmenopausal AI; equally efficacious to anastrozole (BIG 1-98)
4. exemestane 25 mg PO once daily (aromatase_inhibitor, second line) — Steroidal AI option; switch strategy after 2-3 yr tamoxifen (TEAM)
5. abemaciclib 150 mg PO BID x 2 years (CDK4_6_inhibitor, add on) — monarchE (Johnston JCO 2020 PMID 32954927) — 2-year adjuvant abemaciclib + ET improves iDFS in node-positive high-risk HR+/HER2- early breast cancer

AVOID / contraindication checks:
- Tamoxifen_avoid_active_vte_or_endometrial_hyperplasia
- Ai_avoid_premenopausal_unless_ovarian_suppression (SOFT/TEXT framework)
- Abemaciclib_hold_grade_3_4_diarrhea_or_neutropenia_or_ILD
- Bone_density_baseline_q2y_on_AI

Monitoring

Regimen monitoring:
- menstrual status and endometrial symptoms on tamoxifen
- lipid panel q6 12mo on AI
- bone mineral density baseline then q2y on AI
- CBC LFT q2 4wk on abemaciclib first 2 months then monthly
- CT chest for ILD if abemaciclib pulmonary symptoms

Follow-up plan: 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)
- Close-out criterion: Survivorship plan documented with next scan + endocrine duration + cascade-testing plan (NCCN Breast 2026)

Monitoring phase: 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)

Disposition

Disposition phase: 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 when: Care setting and treatment timeline established (NCCN Breast 2026)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Bone metastases with new back pain + neurologic deficit (motor weakness, sensory level, bladder/bowel) — MRI within hours
- [SEVERE] Erythema, peau d-orange, rapidly progressive skin change with biopsy showing dermal lymphatic invasion (T4d) — inflammatory breast cancer (IBC)
- [SEVERE] Corrected Ca >12 mg/dL with metastatic breast cancer — symptomatic (confusion, AKI, arrhythmia)

Citations

- NCCN Breast 2026 + St Gallen 2025 + USPSTF 2024 screening + ASCO 2022 metastatic + NCCN germline 2024 [PMID:32954927](https://pubmed.ncbi.nlm.nih.gov/32954927/)
- Cited evidence (PMID 32101663) [PMID:32101663](https://pubmed.ncbi.nlm.nih.gov/32101663/)
- Cited evidence (PMID 34081848) [PMID:34081848](https://pubmed.ncbi.nlm.nih.gov/34081848/)
- Cited evidence (PMID 29860917) [PMID:29860917](https://pubmed.ncbi.nlm.nih.gov/29860917/)
- Cited evidence (PMID 30516102) [PMID:30516102](https://pubmed.ncbi.nlm.nih.gov/30516102/)

Last reconciled with current guidelines: 2026-05-26.
References