
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
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: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
For this case, is neoadjuvant therapy indicated? If yes, what specific neoadjuvant therapy should be used? Case: 
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
For this case, what surgical approach is indicated? What specific pathology findings should I watch for? Case: 
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
After surgery, what adjuvant therapy should be initiated for this case? Be specific about medications and sequence. Case: 
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
Based on NCCN guidelines, does this patient meet criteria for genetic testing? What about their family? Case: 
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.
What psychosocial support and counseling would you recommend for this patient? Case: 
Demographics:
* Age: 55
* Sex: female
* Race: Black
* Income: middle income
* Zipcode: 10027

55 year old woman, post menopausal, with history of prior hormone positive (ER positive, PR positive), HER2 negative right breast cancer. Stage II on presentation with 3-4 nodes positive. Received right mastectomy and radiation. OncotypeDX score 29 and received adjuvant chemotherapy. Received verzinio and anastrazole for two years, continuing latter. Now presents with new bone and liver metastasis. Biopsy shows hormone positive, HER2 negative (IHC 1+, but FISH negative). NGS without PIK3CA or ESR-1 mutation.