The preparation for breast cancer surgery involves a series of tests designed to accomplish three specific goals: confirming the initial diagnosis, precisely mapping the disease for surgical planning, and ensuring the patient is medically fit for the procedure and anesthesia. This pre-operative process is a coordinated sequence of investigations that allows the surgical and oncology teams to determine the most effective and safest treatment path. These tests provide the essential information required to personalize the surgical approach and subsequent therapies.
Analyzing the Cancer’s Characteristics
Planning treatment requires an analysis of the tumor’s biological makeup, detailed in the pathology report following the original biopsy. This information dictates whether a patient will benefit from systemic treatments—such as chemotherapy, hormone therapy, or targeted therapy—before or after the operation. The tumor tissue is routinely tested for specific biomarkers, which are proteins that influence how the cancer cells grow and respond to different medications.
One of the most important analyses is the Hormone Receptor Status, which looks for the presence of Estrogen Receptors (ER) and Progesterone Receptors (PR) on the cancer cells. If a tumor is positive for either or both of these receptors, it means the cancer cells are fueled by the body’s natural hormones, and the patient will likely benefit from anti-hormone therapy. This testing is typically done using a technique called immunohistochemistry (IHC), where special stains highlight the receptors in the tissue sample.
The second primary biomarker assessment determines the status of Human Epidermal growth factor Receptor 2, known as HER2. This is a protein on the surface of breast cells that controls growth, and when it is overexpressed, it causes the cancer cells to grow and divide rapidly. HER2-positive tumors are aggressive but are highly responsive to specialized targeted therapies that specifically block this protein.
If the initial IHC test for HER2 is ambiguous, a secondary test like Fluorescence In Situ Hybridization (FISH) is performed to confirm the number of HER2 genes present in the cell. The combination of ER, PR, and HER2 results classifies the tumor into a specific subtype, which is fundamental in deciding if the patient should receive chemotherapy or targeted therapy before surgery, a strategy known as neoadjuvant therapy. For instance, a tumor that is negative for all three markers is called triple-negative and requires a different treatment approach.
Tests to Determine Disease Extent
Once the tumor’s biology is understood, the next phase focuses on staging—determining the physical extent and location of the cancer. Local staging uses specialized imaging to define the tumor size and look for other areas of concern within the breast and nearby lymph nodes. An updated mammogram, often a diagnostic or 3D version, confirms the size of the primary tumor and screens for suspicious calcifications or masses in either breast.
Breast Magnetic Resonance Imaging (MRI) is a highly sensitive tool used in many cases to accurately map the extent of the disease, especially for patients with dense breast tissue or specific tumor types. The MRI provides a detailed, three-dimensional view that can sometimes reveal additional, smaller tumors not visible on a mammogram or ultrasound. A high-resolution ultrasound is also routinely used to examine the axillary lymph nodes in the armpit, which are the first place breast cancer cells typically spread.
If the axillary ultrasound shows suspicious lymph nodes, a needle biopsy is performed to check for cancer cells before surgery. For patients with larger tumors or aggressive biological subtypes like HER2-positive or triple-negative cancer, the medical team may recommend distant staging scans. These systemic tests check if the cancer has spread beyond the breast and axilla to other organs, a condition known as metastasis.
Distant staging tests may include a Computed Tomography (CT) scan of the chest, abdomen, and pelvis, or a Positron Emission Tomography (PET) scan. The PET scan uses a radioactive tracer to highlight metabolically active cancer cells anywhere in the body. A bone scan may also be performed to check the skeletal system for any signs of spread. The results of all these imaging tests are integrated with the biological markers to establish the cancer’s clinical stage.
Pre-Anesthesia and General Health Clearance
The final set of tests before surgery focuses entirely on the patient’s overall health to ensure they can safely undergo general anesthesia and recover without complication. These tests are standard procedures for any major operation and are not specific to the breast cancer diagnosis itself. The process usually begins with a pre-assessment clinic appointment, where a nurse or anesthesiologist reviews the patient’s complete medical history, including any medications and pre-existing conditions.
Routine blood work is performed to provide a baseline assessment of the patient’s physiological status. This includes a Complete Blood Count (CBC) to check for anemia or signs of infection, and a metabolic panel to assess kidney and liver function. Coagulation studies are also conducted to measure the blood’s ability to clot, which is an important safety measure against excessive bleeding during the operation.
An electrocardiogram (EKG or ECG) is a standard requirement to record the electrical activity of the heart and check for underlying heart rhythm abnormalities. For patients with pre-existing heart or lung conditions, a chest X-ray or specialized breathing tests may be ordered to ensure the respiratory system can handle the stress of surgery and the effects of anesthesia. The anesthesiologist reviews all these results to develop a personalized anesthesia plan.