Skill Checkup: A 56-Year-Old Woman With a History of Breast Cancer and Pain in Her Ribs and Spine

Pavani Chalasani, MD, MPH;  Stefania Morganti, MD


January 23, 2023

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 56-year-old Black woman presents for follow-up 2 years after primary treatment for early-stage hormone receptor (HR)–positive, human epidermal growth factor receptor 2 (HER2)–negative cancer in her left breast. She underwent left mastectomy with sentinel node biopsy. Pathologic tumor stage was pT2 (4 cm) pN0. An Oncotype Dx test was requested which showed a recurrence score of 40. In addition, given her family history of breast cancer (an aunt and a cousin), she underwent genetic testing and was negative for BRCA1/2 pathogenic variants. She received adjuvant chemotherapy and then started on an aromatase inhibitor. Owing to side effects, she switched to tamoxifen within 2 months.

The patient has two grown children, does not smoke, is 5 ft 6 in tall (1.676 m), and weighs 150 lb (68.04 kg) BMI, 24.2). Her vitals in clinic are a temperature of 98.1 °F (36.7 °C), pulse of 50 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 139/75 mm Hg.

She now reports recent pain in her spine and ribs that has become increasingly bothersome. On workup, a complete blood count and complete metabolic profile were essentially unremarkable, except for an alkaline phosphatase level that was elevated at 620 U/L (upper limit of normal in laboratory, 140 U/L). She underwent PET-CT, which identified bone lesions in the spine, hips, ribs, and skull, without evidence of metastases in visceral sites.


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