Clinical practice guidelines for pre-operative evaluation of breast cancer: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021



## Level of evidence and recommendation strength
Level of evidence standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength review committee A total of 84 members of the voting committee of this guideline, including 71 breast surgeons (84.52%), four oncologists (4.76%), four radiologists (4.76%), two pathologist (2.38%), two radiation therapist (2.38%), and one epidemiologist (1.19%).

## Target audience
Chinese breast disease specialists.

## Recommendations
Recommendation 1: General evaluation.

## Component

## Level of evidence
Strength of recommendation 1.1 Evaluation of vital signs [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.2 Laboratory evaluation [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.3 Clinical examination [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.4 Blood pressure monitoring and related pre-operative managementI A 1.5 Glucose monitoring and related pre-operative managementI A 1.6 Specific clinical conditions in patients with breast cancer 1.6.1 Cardiovascular disease or risk factors [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac..., Fleisher [/bib_ref] I A 1.6.2 Respiratory disease, smoking habit, obstructive sleep apnea syndrome [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.3 Liver disease [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.4 Renal disease [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.5 Diabetes [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.6 Old age [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Risk assessment for and strategies to reduce perioperative pulmonary complications for patients..., Qaseem [/bib_ref] I A 1.6.7 Obesity [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Risk assessment for and strategies to reduce perioperative pulmonary complications for patients..., Qaseem [/bib_ref] I A 1.6.8 Anemia [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.9 Coagulation disorders [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I A 1.6.10 Risk factors for thrombosis [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Guidelines for the prevention and management of perioperative thrombosis in general surgery..., Liu [/bib_ref] I A 1.6.11 Electrolyte disturbances [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] I AII A b. To define extent of cancer or presence of multifocal or multicentric cancer in the ipsilateral breastII A c. Occult (or unidentified) primary breast cancer with axillary lymph node metastasesII A 3.1.4 Determination of tumor estrogen/progesterone receptor and human epidermal growth factor receptor-2 statusI A 3.2 Evaluation of regional lymph nodes 3.2.1 Needle biopsy of suspicious lymph nodesI A

## Component

## Level of evidence
Strength of recommendation standard staging studies, locally advanced breast cancer (IIIA and above), and/or distant metastases3.4 Concomitant evaluation of patients with breast cancer 3.4.1 Genetic counseling if patient is at risk of hereditary breast cancer [bib_ref] Early breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up..., Cardoso [/bib_ref] II A 3.4.2 Pregnancy testing in all potentially pregnant womenII A 3.4.3 Assessment of mental health statusII A 3.5 Evaluation of neoadjuvant therapy 3.5.1 Marking of tumor before commencing neoadjuvant therapyII A 3.5.2 Imaging evaluation every two cyclesII A 3.5.3 Primary tumor evaluation after neoadjuvant therapy a. Breast ultrasound [bib_ref] ACR appropriateness criteria(  ) monitoring response to neoadjuvant systemic therapy for..., Slanetz [/bib_ref] I A b. Breast MRI [bib_ref] ACR appropriateness criteria(  ) monitoring response to neoadjuvant systemic therapy for..., Slanetz [/bib_ref] II A c. If the lesion was clearly shown on a pre-treatment mammogram, mammography can be repeated after neoadjuvant therapy [bib_ref] ACR appropriateness criteria(  ) monitoring response to neoadjuvant systemic therapy for..., Slanetz [/bib_ref] II A 3.5.4 Regional lymph node evaluation after neoadjuvant therapy a. Breast ultrasound [bib_ref] ACR appropriateness criteria(  ) monitoring response to neoadjuvant systemic therapy for..., Slanetz [/bib_ref] I A b. Breast MRI [bib_ref] ACR appropriateness criteria(  ) monitoring response to neoadjuvant systemic therapy for..., Slanetz [/bib_ref] II A CT: Computed tomography; MRI: Magnetic resonance imaging; PET: Positron emission tomography.

# Discussion
Pre-operative evaluation is an important aspect of the surgical treatment of breast cancer, basically determining the success or failure of such surgery, including whether it is curative. Surgeons should make pre-operative evaluation a high priority, especially for older or frail patients and those with serious comorbidities. [bib_ref] Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the..., Hert [/bib_ref] [bib_ref] Practice advisory for preanesthesia evaluation: an updated report by the American Society..., Apfelbaum [/bib_ref] The CSBrS panel recommends that patients with breast cancer should also be subjected to pre-operative oncology evaluation [bib_ref] Early breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up..., Cardoso [/bib_ref] by breast ultrasound, mammography, and breast magnetic resonance imaging (MRI) to identify the number of lesions, their locations and size, regional lymph node status, and distant metastases. [bib_ref] Early breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up..., Cardoso [/bib_ref] [bib_ref] AGO recommendations for the diagnosis and treatment of patients with early breast..., Ditsch [/bib_ref] [bib_ref] ACR appropriateness criteria(  ) palpable breast masses, Moy [/bib_ref] Tumor node metastasis stage should be determined in accordance with the eighth edition of the Cancer Staging Manual issued by the American Joint Committee on Cancer. The CSBrS panel stresses that the application value of breast MRI should be fully understood: it has high sensitivity and can show multi-focal, multi-centric, or occult tumors, the relationship between tumor and chest wall, and axillary lymph node metastasis, thus providing a reliable basis for development of a surgical plan. However, it is only moderately specific, does not satisfactorily display microcalcification, and sometimes produces false positives. Thus, decisions about surgery cannot be made purely on the basis of MRI findings. [bib_ref] Early breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up..., Cardoso [/bib_ref] [bib_ref] AGO recommendations for the diagnosis and treatment of patients with early breast..., Ditsch [/bib_ref] [bib_ref] ACR appropriateness criteria(  ) palpable breast masses, Moy [/bib_ref] Appendix: Additional discussion section (Supplementary file, http://links.lww.com/CM9/A804)

## Conflicts of interest
The expert committee for these guidelines declares no conflict of interest.
These guidelines are a reference for breast disease specialists in clinical practice. However, the guidelines are not to be used as the basis for medical evaluation, and do not play an arbitrating role in the handling of any medical disputes. The guidelines are not a reference for patients or non-breast specialists. The Chinese Society of Breast Surgery assumes no responsibility for results involving the inappropriate application of these guidelines, and reserves the right to interpret and revise the guidelines.
List of compiling committees (In alphabetical order by surname)
 Chinese Medical Journal 2021;134(18) www.cmj.org