What is the initial workup for suspected breast cancer in the emergency room (ER)?

Emergency Department Workup for Suspected Breast Cancer

In the emergency department, suspected breast cancer requires immediate breast ultrasound as the primary imaging modality, followed by core needle biopsy of any suspicious lesions, with mammography deferred to outpatient follow-up unless the patient has no established care pathway. 1

Critical First Steps in the ED

Clinical Assessment

• Document onset and duration of symptoms (rapid onset suggests inflammatory breast cancer if <6 months), presence of erythema occupying at least one-third of the breast, peau d'orange, breast warmth, palpable masses, nipple discharge characteristics, and skin changes 2
• Perform systematic breast examination both upright and supine, assess for lymphadenopathy in axillary and supraclavicular regions, and document exact location and size of any masses 3
• Obtain menstrual history, family history of breast/ovarian cancer, and prior breast disease 2

Immediate Imaging in the ED

Ultrasound is the preferred and most practical initial imaging modality in the emergency department setting because it is readily available, requires no breast compression, provides real-time visualization, and effectively characterizes solid versus cystic lesions. 4, 1

• Perform targeted ultrasound of the symptomatic breast and bilateral axillae using high-resolution linear-array transducer with minimum 10 MHz frequency 4
• Ultrasound can detect 93-100% of cancers that are occult on mammography and provides immediate characterization of masses 4
• If a simple cyst is identified, this is benign (BI-RADS 2) and requires only routine follow-up 5, 4

Tissue Diagnosis Before Any Intervention

Core needle biopsy must be obtained before any treatment attempt, including attempted drainage of suspected abscesses. 2, 1

• If ultrasound shows a solid mass or suspicious features, perform ultrasound-guided core needle biopsy immediately in the ED if expertise is available, obtaining at least 2-3 cores 2, 4
• Never attempt to drain a breast mass without prior imaging—breast cancer commonly mimics abscess and mastitis 1
• If core biopsy capability is unavailable in the ED, arrange urgent outpatient biopsy within 24-48 hours and prescribe symptomatic management only (not antibiotics unless clear infectious signs) 1

Laboratory Studies

Obtain basic laboratory work including:

• Complete blood count 3
• Comprehensive metabolic panel including liver function tests, alkaline phosphatase, and calcium 2
• These help assess for potential metastatic disease and establish baseline values 3

What NOT to Do in the ED

Common pitfalls that delay diagnosis and worsen outcomes:

• Do not prescribe antibiotics and discharge without imaging—this is the most dangerous error, as inflammatory breast cancer and other malignancies mimic infection 1
• Do not attempt aspiration or drainage of any breast mass without prior ultrasound confirmation of a simple cyst 1
• Do not rely solely on clinical examination—physical findings alone have poor sensitivity and specificity 4
• Do not order routine metastatic staging (chest X-ray, CT, bone scan) in the ED unless the patient has symptoms suggesting metastases, locally advanced disease, or high tumor burden 3

Disposition and Follow-Up

If Biopsy Confirms Malignancy in ED

• Arrange urgent referral to breast surgery/oncology within 3-5 days 6
• Delays beyond 60 days from diagnosis to treatment initiation increase mortality by 66-85% in late-stage disease 6
• Provide patient with written instructions for immediate follow-up and contact information for breast center 1

If Biopsy Shows Benign Findings

• Ensure concordance between pathology, imaging, and clinical findings—discordance requires surgical excision 4
• Arrange outpatient follow-up within 1-2 weeks for definitive management plan 5

If No Biopsy Performed in ED

• Mandatory outpatient follow-up within 24-48 hours at breast center for diagnostic mammography and biopsy 1
• Document clear follow-up plan in discharge instructions with specific appointment details 1
• Do not discharge with "follow up with primary care"—direct referral to breast imaging/surgery is required 1

Special Consideration: Inflammatory Breast Cancer

If clinical presentation suggests inflammatory breast cancer (rapid onset <6 months, erythema covering ≥1/3 of breast, peau d'orange, warmth):

• Obtain core biopsy of breast tissue AND skin punch biopsy (at least two samples) 2
• Dermal lymphovascular invasion on skin biopsy is pathognomonic but not required for diagnosis 2
• These patients require immediate multidisciplinary referral as they need neoadjuvant chemotherapy before surgery 2

Documentation Requirements

Document in ED chart:

• Exact location, size, and characteristics of any masses 3
• Results of ultrasound with BI-RADS category if available 4
• Whether core biopsy was performed and number of cores obtained 2
• Specific follow-up arrangements made, including date/time of appointments 1
• Patient counseling about importance of follow-up and potential for malignancy 1