Case Study: Breast Oncology APPs Across the Cancer Continuum

Case Study

A 28-year-old woman, “K.C.,” presented to the high-risk breast clinic 2 weeks after the identification of a BRCA2 pathogenic variant (c.5331dupA, heterozygous) via a genetic test. She reported a family history of cancer, including a paternal first cousin with a pathogenic BRCA2 mutation diagnosed with triple-negative breast cancer (TNBC) at 33 years old. Following the cousin’s disclosure of her genetic testing results, the patient’s father had genetic testing that identified the same BRCA2 mutation.

The patient then obtained testing via her primary care provider, also confirming a BRCA2 pathogenic variant. Formal genetic counseling was not provided. She was referred to a comprehensive breast clinic to establish care with a surgical oncology advanced practice provider (APP) for high-risk management.

At the time of K.C.’s visit, she denied breast symptoms or health concerns. Her only prior breast imaging included a right breast ultrasound that identified a symptomatic breast cyst. On physical examination, a palpable mass (3 by 2 cm) was identified in the left breast at 4:00, approximately 4 cm from the nipple.

The APP ordered a bilateral diagnostic mammogram and left breast ultrasound that revealed extremely dense breast tissue, a right breast simple cyst, and a left breast indeterminate, oval, hypoechoic 1.0 by 1.3 by 1.2 cm mass with angular and indistinct margins at the area of palpable concern.

K.C.’s breast imaging–reporting and data system (BI-RADS) score was 4 with a recommendation for ultrasound-guided biopsy. Pathology confirmed high-grade and high-rate invasive mammary carcinoma, with no special type and clinical stage T2N0-1 TNBC.

Although she was initially seeking care for high-risk management, K.C.’s physical exam and subsequent workup resulted in a malignant diagnosis. As part of a multidisciplinary team, the breast APP facilitated K.C.'s breast biopsy as well as complex patient discussions regarding her new diagnosis. The breast APP coordinated additional imaging evaluation with breast MRI, as well as consultations with genetics, surgical oncology, medical oncology, radiation oncology, and plastic surgery.

At age 28, K.C. was actively trying to conceive at the time of her diagnosis, and she was referred to a fertility specialist to discuss fertility preservation. In collaboration with an interdisciplinary team within an academic cancer center, K.C. was recommended to start neoadjuvant therapy with dose-dense adjuvant doxorubicin (Adriamycin) and cyclophosphamide, followed by paclitaxel (ddAC-T), followed by bilateral nipple-sparing mastectomy with implant-based reconstruction.

Understanding Breast Cancer Risk, Genetic Mutations, and Screening Recommendations

Breast cancer is the most common cancer worldwide and is the second leading cause of cancer-related death among women in the US.¹ The average risk for breast cancer development in the general population in the US is 12.5% for females and 0.1% for males.² Incidence rates have risen by 1% annually in recent years, with a slightly higher increase (1.4%) among women under 50.³ This is attributed to risk factors such as excess body weight, nulliparity, or having a first child after age 30.

Moreover, when compared with older women, young women are more likely to develop breast cancer with more aggressive biological features, including larger tumor size, advanced tumor stage, negative hormone receptor status (estrogen receptor and progesterone receptor), and overexpression of EGFR, all contributing to poorer prognosis.⁴ Additionally, excluding women at high risk for the disease, breast cancer screening is not widely recommended for those under 40 years old.⁵

Approximately 5% to 10% of breast cancers are caused by germline mutations. BRCA1 and BRCA2 are genes responsible for tumor suppression whose mutations significantly increase the chance of breast and other cancers.² Women with BRCA1 or BRCA2 mutations have a 70% cumulative lifetime risk of developing breast cancer compared with the general population.⁶ Certain populations exhibit a higher likelihood of harboring a genetic mutation. These include Ashkenazi Jewish patients as well as any male patients and patients younger than 30 years old with breast cancer.²

For patients with a pathogenic BRCA mutation, National Comprehensive Cancer Network (NCCN) guidelines recommend enhanced breast cancer screening to promote early detection of high-risk lesions or breast malignancy.⁷ Additional recommendations include breast awareness starting at age 18, clinical breast exams every 6 to 12 months beginning at age 25, annual mammograms with tomosynthesis, and annual breast MRI from ages 25 to 75.^5,7 Alternating schedules with mammograms and MRIs every 6 months is a favored approach for high-risk care.^4,5 Risk-reducing mastectomy and preventive medications, such as tamoxifen or exemestane, have been shown to lower breast cancer risk in high-risk individuals.^4,7

APP Roles in Breast Oncology

The specialized breast health nurse practitioner role has been described in the literature as an effective approach to high-risk care, including genetic testing, breast imaging, and risk-reduction strategies.^8,9 Within this case, the specialty breast APP served as the initial provider to discuss high-risk management, but upon clinical exam, detected a suspicious mass and facilitated diagnostic workup. Prior contributions by this team have displayed APP-driven workflows that have enhanced access to oncology care while achieving outstanding patient satisfaction.^10,11

While there is limited data regarding the precise number of APPs practicing within oncology, an estimated 5350 to 10,750 APPs are employed in oncology, most of whom spend most of their time in direct delivery of patient care.¹² Within breast oncology, APPs are integral from the time of cancer screening, throughout cancer treatment, and within survivorship teams.

Oncology APPs function within ambulatory clinics, infusion centers, and inpatient settings to provide personalized care for women undergoing active treatment. During follow-up clinic visits, APPs monitor patients for signs and symptoms of treatment adverse effects and disease progression or recurrence. Routine follow-up appointments promote timely referrals for specialized services, such as physical therapy and lymphedema therapy, among others, to optimize patient outcomes.

Once the active treatment phase is completed, APPs within survivorship clinics play a crucial role in helping patients manage late effects following their cancer treatment. They create individualized breast cancer survivorship plans that include a detailed treatment summary, outlining potential long-term effects, providing follow-up care guidance, and ensuring seamless coordination of care between the oncology team and the patient’s primary care provider. Additionally, APPs educate patients on strategies for cancer risk reduction, such as maintaining regular physical activity and striving to achieve and sustain a healthy weight.

Conclusion

The American Cancer Society projected 2 million new cancer diagnoses in the US for 2025, including 319,950 new cases of invasive breast cancers.³ Furthermore, the estimated 5-year survival rate for all cancers combined is 69% for those diagnosed from 2014 to 2020. As the numbers of cancer cases and long-term survivors grow, this underscores the expanding demand for specialty oncology providers. However, oncology workforce challenges persist. With an estimated 19.7% of oncologists nearing retirement, only 15.6% of oncologists are aged 40 or younger, highlighting a concerning physician shortage.¹³ APPs have successfully integrated within all aspects of oncology care, thus offering a broad range of skills and services to support patients. As oncology patient volumes continue to rise, specialty-trained APPs are well-positioned to help bridge the gap throughout the cancer continuum.

References

1. Patel MM, Adrada BE. Hereditary breast cancer: BRCA mutations and beyond. Radiol Clin North Am. 2024;62(4):627-642. doi:10.1016/j.rcl.2023.12.014
2. Casaubon JT, Kashyap S, Regan JP. BRCA1 and BRCA2 mutations. In: StatPearls. StatPearls Publishing; 2023. Accessed November 5, 2025. https://www.ncbi.nlm.nih.gov/books/NBK470239/
3. American Cancer Society. Cancer Facts & Figures 2025. Accessed November 6, 2025. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2025/2025-cancer-facts-and-figures-acs.pdf
4. Mainor CB, Isaacs C. Risk management for BRCA1/BRCA2 mutation carriers without and with breast cancer. Curr Breast Cancer Rep. 2020;12(2):66-74. doi:10.1007/s12609-019-00350-2
5. NCCN. Clinical Practice Guidelines in Oncology. Breast cancer screening and diagnosis, version 2.2025. Accessed November 5, 2025. https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf
6. Shubeck S, Sevilimedu V, Berger E, Robson M, Heerdt AS, Pilewskie ML. Comparison of outcomes between BRCA pathogenic variant carriers undergoing breast-conserving surgery versus mastectomy. Ann Surg Oncol. 2022;29(8):4706-4713. doi:10.1245/s10434-022-11756-1
7. NCCN. Clinical Practice Guidelines in Oncology. Genetic/familial high-risk assessment: breast, ovarian, pancreatic, and prostate, version 1.2026. Accessed August 19, 2025. https://www.nccn.org/professionals/physician_gls/pdf/genetics_bopp.pdf
8. Laws A, Mulvey TM. Implementation of a high-risk breast clinic for comprehensive care of women with elevated breast cancer risk identified by risk assessment models in the community. JCO Oncol Pract. 2021;17(2):e217-e225. doi:10.1200/OP.20.00256
9. Senter L, Hatfield R. Nurse practitioners & genetic counselors: collaborative roles in a complex system. Nurse Pract. 2016;41(7):43-49. doi:10.1097/01.NPR.0000470355.00838.a2
10. Johnson AB, Beck ML, Jackson HJ. The impact of a nurse-led high-risk referral protocol implemented in a comprehensive breast center. Clin J Oncol Nurs. 2024;28(4):366-371. doi:10.1188/24.CJON.366-371
11. Johnson A, Jackson H. Utilization of nurse practitioners to improve access to care for newly diagnosed breast cancer patients: a pilot study. Presented at: 2022 American Association of Nurse Practitioners National Conference; June 21-26, 2022; Orlando, FL.
12. Bruinooge SS, Pickard TA, Vogel W, et al. Understanding the role of advanced practice providers in oncology in the United States. JAAPA. 2018;31(12):1-12. doi:10.1097/01.JAA.0000549592.10756.4a
13. 2020 snapshot: state of the oncology workforce in America. JCO Oncol Pract. 2021;17(1):e464-e469. doi:10.1200/OP.20.00577