Breast cancer is the most common cancer and the second most common cause of cancer-related death in women in the United States.1 The breast cancer screening recommendations for an average risk woman are, however, somewhat controversial, though often include mammography and physical exam. As breast cancer can be asymptomatic or have a series of different symptoms and physical exam findings, a screening approach should be individualized for each patient.
The most common sites of breast cancer metastases are the lymph nodes, lungs, bone, and liver.2 Patients with metastatic disease can, however, have the same physical exam findings and clinical symptoms as early stage breast cancer. Lymphadenopathy should be evaluated in the axilla, chest wall, head and neck, abdomen, groin, and lower extremities. As the test is not reliable, if a health care practitioner does not palpate any suspicious lymph nodes, especially in the axilla, it should not be assumed that the patient has no lymph node involvement.
Patients with lung metastases may complain of shortness of breath and have an abnormal pulmonary exam. Liver metastases may present with jaundice, nausea, vomiting, and right upper quadrant abdominal pain on exam. Bone metastases will frequently cause pain; if this complaint is noted, a musculoskeletal exam should be performed. It is important to perform a thorough review of systems and physical exam in patients with breast cancer without known metastatic disease, as these may help prompt the early detection of metastases.
If a patient is diagnosed with metastatic disease, the overall prognosis is poor: the median overall (OS) survival is approximately 24 months.3 Patients with metastases to the liver and lungs have a worse prognosis compared with those with metastases to the lymph nodes or bones.4
Hormone receptor positivity in metastatic disease also has an impact on survival, as those patients with estrogen receptor (ER) and progesterone receptor (PR) positivity usually have a longer OS.5 Other factors associated with a poor prognosis in the metastatic setting include being younger than 35 years old, having elevated lactic dehydrogenase, weight loss, and overall poor performance status.2