History The patient has a medical history of nonalcoholic steatohepatitis with cirrhosis and chronic pancreatitis. She underwent bilateral mastectomy with right axillary lymph node dissection 3 years ago for breast cancer. Pathology returned grade 3 invasive ductal carcinoma measuring 1.8 cm with lymphovascular invasion. Baseline CT scans of the chest, abdomen, and pelvis performed as well as a whole body Tc99m bone scan performed a month postoperatively showed no evidence of metastasis. Due to the tumor size and presence of lymphovascular invasion, dose-dense doxorubicin and cyclophosphamide (dd AC) followed by weekly paclitaxel was recommended. The patient was counseled on potential adverse reactions before treatment initiation. After therapy was offered and informed consent was obtained, she elected to proceed. Chemotherapy with dd AC every 2 weeks began 1 month postoperatively and concluded after four treatment cycles. The patient was given 6 mg of pegfilgrastim 27 hours after completion of each dd AC infusion.