
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
Your reply should be structured in the following format:

Case summary: Summarize the salient features of the case

Neoadjuvant therapy: Is neoadjuvant therapy indicated? If yes, what neoadjuvant therapy should be used.

Surgery: Is surgery indicated here? Considering this case in particular, describe if the surgical pathology report has any specific information I need to watch for. If yes, what information do I need to look for?

Adjuvant therapy: After surgery, what therapy should be initiated? (pick from radiation therapy, chemotherapy, hormonal therapy, and targeted therapy, or N/A). Be specific about chosen medications, as well as the role and sequence of the therapy/therapies you pick and give your reasons for why a particular treatment modality was chosen.

Genetic testing: Per NCCN guidelines, does this patient meet criteria for genetic testing? What about their family?

Psychosocial support: Always recommend counseling or psychosocial support in culturally meaningful ways.

Case text: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
For this case, is neoadjuvant therapy indicated? If yes, what specific neoadjuvant therapy should be used? Case: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
For this case, what surgical approach is indicated? What specific pathology findings should I watch for? Case: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
After surgery, what adjuvant therapy should be initiated for this case? Be specific about medications and sequence. Case: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
Based on NCCN guidelines, does this patient meet criteria for genetic testing? What about their family? Case: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.
What psychosocial support and counseling would you recommend for this patient? Case: 
Demographics:
* Age: 59
* Sex: female
* Race: American Indian
* Income: middle income
* Zipcode: 90210

59 year old, post-menopausal female with history of metastatic hormone positive (ER positive, PR positive, HER2 negative) breast cancer with bone and liver involvement. Had POD on anastrazole and ribociclib. Next generation sequencing (NGS) shows ESR-1 mutation. She was changed to fulvestrant and ribociclib. Now presenting with new symptomatic malignant pleural effusion.