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Clinical Staging Of Breast Cancer

Adoption Of The Prognostic Stage

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For the 8th edition, the AJCC committee created the prognostic staging protocol. This integrates biomarkers into the TNM staging system, making use of the results from large cohort studies, which shows that not only pathologic stage, but also different biomarkers could affect survival . The biomarkers indicate tumor grade, hormone receptor status, and HER2. Multigene panel status is also incorporated into the staging system in limited sub-groups. The 8th edition defines clinical and pathologic prognostic stages that combine anatomic staging with tumor grade, hormone receptor status, and HER2 status .

Pathologic Prognostic Stage is assigned to patients who received surgery as initial treatment.

Additionally, pT1, pT2, pN0, M0, ER+, and HER2 cancers are assigned as Pathologic Prognostic Stage group IA when Oncotype DX recurrence score is less than 11.

Hormone Receptor And Her2 Expression

Evaluating the expression of estrogen receptors and progesterone receptors in breast cancer is important, because selective ER modulators slow the progression of ER-positive and PR-positive tumors . Furthermore, breast cancer is related to several oncogenes including HER2. The presence of HER2 is associated with a poor prognosis in untreated patients . However, HER2 targeting agents improve the prognosis for patients with HER2 positive tumors . A high Ki-67 level reflects rapidly dividing tumor cells, although there is no universal cut-off for measuring Ki-67 levels . According to the ER/PR and HER2 status and with additional information about Ki-67, the 8th edition identifies four subtypes: luminal A , luminal B , HER2 , and basal . The luminal A type has the best prognosis, with excellent response to endocrine therapies. The luminal B type is less responsive to endocrine therapies and has worse prognosis than the luminal A type. The HER2 type responds to HER2 targeting agents and proper treatment improves the prognosis. The basal type, also known as a triple-negative tumor, has the worst prognosis .

cT1N0M0 cancer.

MRI shows that cancer measures 1.3 cm . There is no suspicious lymph node enlargement. Pathology shows 0.9-cm grade-2 carcinoma, but no hormone receptor or HER2 overexpression is noted. Therefore, anatomic stage is IA , but it is triple negative cancer thus, Clinical and Pathologic Prognostic Stages are higher, IB.

What Is Cancer Staging

Staging is a way of describing how extensive the breast cancer is, including the size of the tumor, whether it has spread to lymph nodes, whether it has spread to distant parts of the body, and what its biomarkers are.

Staging can be done either before or after a patient undergoes surgery. Staging done before surgery is called the clinical stage, and staging done after surgery is called the pathologic stage. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor recommend the best kind of treatment and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

This page provides detailed information about the system used to find the stage of breast cancer and the stage groups for breast cancer, such as stage IIA or stage IV.

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Physical Emotional And Social Effects Of Cancer

In general, cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Supportive care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive supportive care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Supportive care treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies.

  • Music therapy, meditation, stress management, and yoga for reducing anxiety and stress.

  • Meditation, relaxation, yoga, massage, and music therapy for depression and to improve other mood problems.

  • Meditation and yoga to improve general quality of life.

  • Acupressure and acupuncture to help with nausea and vomiting from chemotherapy.

Why Were New Measures Added To The Staging System

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The new measures give information on the biology of the tumor that affects prognosis. Adding these measures improved staging.

For example, with breast cancer, a large tumor may have a better prognosis than a small tumor, based on biological measures. In the same way, a small tumor may have a worse prognosis than a large tumor based on these measures.

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N Categories For Breast Cancer

N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are involved.

Lymph node staging for breast cancer is based on how the nodes look under the microscope, and has changed as technology has gotten better. Newer methods have made it possible to find smaller and smaller groups of cancer cells, but experts haven’t been sure how much these tiny deposits of cancer cells influence outlook.

Its not yet clear how much cancer in the lymph node is needed to see a change in outlook or treatment. This is still being studied, but for now, a deposit of cancer cells must contain at least 200 cells or be at least 0.2 mm across for it to change the N stage. An area of cancer spread that is smaller than 0.2 mm doesn’t change the stage, but is recorded with abbreviations that indicate the type of special test used to find the spread.

If the area of cancer spread is at least 0.2 mm , but still not larger than 2 mm, it is called a micrometastasis . Micrometastases are counted only if there aren’t any larger areas of cancer spread. Areas of cancer spread larger than 2 mm are known to influence outlook and do change the N stage. These larger areas are sometimes called macrometastases, but are more often just called metastases.

NX: Nearby lymph nodes cannot be assessed .

N0: Cancer has not spread to nearby lymph nodes.

N1c: Both N1a and N1b apply.

N3: Any of the following:

N3a: either:

N3b: either:

What Are The Stages Of Breast Cancer

Breast cancer staging uses Roman numerals 0, I, II, III and IV, with 0 being noninvasive cancer cells in one spot and IV being invasive breast cancer that has spread into other areas of the body. The five numerals have A and B subcategories that look at other factors such as lymph node involvement and metastases .

The American Joint Committee on Cancer uses the letters T, N and M to characterize three different aspects of breast tumors.

T: Tumor

This designation looks at the tumor, its size and whether or not the cancer has invaded surrounding tissue.

The T designation has several categories:

  • TX means the tumor is not assessed.
  • T0 means there is no evidence of invasive breast cancer.
  • T1, T2 and T3 refer to the size of the tumor and consider if and how far it has invaded surrounding breast tissue.

N: Nodes

  • An important aspect of staging breast cancer has to do with whether the cancer has spread to one or more nearby lymph nodes fluid channels in the breast. The N value describes if and how the cancer has infiltrated one or more lymph nodes near the breast. NX means lymph nodes have not been evaluated.
  • N0 means there is no cancer detected in the nearby lymph nodes.
  • N1, N2 and N3 mean that breast cancer is in the lymph nodes. The higher the number, the more advanced the lymph node involvement. These cancers have an increased risk of spreading beyond the breast to lymph nodes and to other organs within the body, says Tran.

M: Metastasis

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What Is Stage Iv Breast Cancer

Stage IV is the most advanced stage of breast cancer. It has spread to nearby lymph nodes and to distant parts of the body beyond the breast. This means it possibly involves your organs such as the lungs, liver, or brain or your bones.

Breast cancer may be stage IV when it is first diagnosed, or it can be a recurrence of a previous breast cancer that has spread.

Clinical Staging Of Breast Cancer

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The determination of whether your cancer is invasive or noninvasive , the information gathered from your medical history and physical examination, as well as an evaluation of your initial breast imaging are all considered when identifying your breast cancers clinical stage. Once that stage is identified, your physician will be able to suggest the most appropriate treatment options.

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Treatment Of Breast Cancer By Stage

This information is based on AJCC Staging systems prior to 2018 which were primarily based on tumor size and lymph node status. Since the updated staging system for breast cancer now also includes estrogen receptor , progesterone receptor , and HER2 status, the stages may be higher or lower than previous staging systems. Whether or not treatment strategies will change with this new staging system are yet to be determined. You should discuss your stage and treatment options with your doctor.

The stage of your breast cancer is an important factor in making decisions about your treatment options. In general, the more the breast cancer has spread, the more treatment you will likely need. But other factors can also be important, such as:

  • If the cancer cells have hormone receptors
  • If the cancer cells have large amounts of the HER2 protein
  • If the cancer cells have a certain gene mutation
  • Your overall health and personal preferences
  • If you have gone through menopause or not
  • How fast the cancer is growing and if it is affecting major organs like the lungs or liver

Talk with your doctor about how these factors can affect your treatment options.

Stage 0 cancers are limited to the inside of the milk duct and are non-invasive .

Ductal carcinoma in situ is a stage 0 breast tumor.

Prognosis In Breast Cancer: The Relevance Of Clinical Staging

A retrospective analysis has been made of a consecutive series of 3924 cases of breast carcinoma in women seen in one centre subject to a consistent management policy between 1954 and 1964. Survival was studied in relation to the clinical stages of the disease as defined by three different staging systems, Manchester, International TNM and that of the International Union Against Cancer and the American Joint Committee on Cancer Staging and End Results Reporting . In spite of considerable differences in the distribution of cases between stages according to the system applied there was markedly little difference in survival rates up to 20 years when each stage was compared with the other two. The most important prognostic factor used in staging is the size of the primary tumour. Although the frequency of clinical evidence of spread outside the breast is related to tumour size, significantly higher 20-year survival rates were found for patients in whom the tumour appeared to be confined to the breast on clinical examination when compared with patients in whom there was clinical evidence of spread beyond the breast only for tumours less than 5 cm maximum diameter. These results suggest that staging systems relying wholly on restricted clinical criteria are of limited value in terms of prognosis and their overfrequent modification is not justified.

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The Tnm Staging System

The breast cancer staging system, called the TNM system, is overseen by the American Joint Committee on Cancer . The AJCC is a group of cancer experts who oversee how cancer is classified and communicated. This is to ensure that all doctors and treatment facilities are describing cancer in a uniform way so that the treatment results of all people can be compared and understood.

In the past, stage number was calculated based on just three clinical characteristics, T, N, and M.

The T category describes the original tumor:

  • HER2 status: are the cancer cells making too much of the HER2 protein?

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    Oncotype DX score, if the cancer is estrogen-receptor-positive, HER2-negative, and there is no cancer in the lymph nodes

Adding information about tumor grade, hormone-receptor status, HER2 status, and possibly Oncotype DX test results has made determining the stage of a breast cancer more complex, but also more accurate.

In general, according to experts, the new staging system classifies triple-negative breast cancer at a higher stage and classifies most hormone receptor-positive breast cancer at a lower stage.

You also may see or hear certain words used to describe the stage of the breast cancer:

  • Distant: The cancer is found in other parts of the body as well.

The updated AJCC breast cancer staging guidelines have made determining the stage of a cancer a more complicated but accurate process. So, the characteristics of each stage below are somewhat generalized.

Breast Cancer Tumor Grade

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The tumors grade is a measurement of how aggressive the cancer cells appear to be. This will give the oncologist a better idea of how quickly the cancer is likely to grow and spread.

To describe how abnormal the cancer cells and tissue are, the pathologist will assess the following three features:

  • How much of the tumor tissue has normal breast ducts.
  • The size and shape of the nuclei in the tumor cells.
  • How many dividing cells are present, which is a measure of how fast the tumor cells are growing and dividing.
  • For each feature, the pathologist assigns a score of 1 to 3 a score of 1 means the cells and tumor tissue look the most like normal cells and tissue, and a score of 3 means the cells and tissue look the most abnormal. The scores for each feature are added together to get a total score between 3 and 9.

    Three grades of breast cancer are possible:

    • Total score of 3 to 5: G1 .
    • Total score of 6 to 7: G2 .
    • Total score of 8 to 9: G3 .

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    Treatment For Stage 2 Breast Cancer

    The most common for stage 2 breast cancer is surgery.

    Surgery

    In most cases, treatment involves removing the cancer. The person may undergo a lumpectomy or mastectomy. The doctors and the individual can decide based on the size and location of the tumor. The surgeon may also remove one or more lymph nodes.

    Combination therapy

    A doctor may recommend a combination of radiation therapy, chemotherapy, and hormone therapy to people with stage 2A or 2B breast cancer.

    Neoadjuvant therapy

    In some cases, a doctor may recommend neoadjuvant therapy, which is chemotherapy before surgery to reduce the size of a tumor.

    The subcategories for stage 3 breast cancer are 3A, 3B, and 3C.

    3A breast cancer is an invasive breast cancer where:

    • There is no tumor in the breast, or a tumor of any size is growing alongside cancer found in four to nine axillary lymph nodes or the lymph nodes by the breastbone.
    • A person has a tumor greater than 5 cm. They also have clusters of breast cancer cells in the lymph nodes that are between 0.22 mm in diameter.
    • The tumor is larger than 5 cm. The cancer has also spread to one to three axillary lymph nodes or the lymph nodes near the breastbone.

    Stage 3B breast cancer is invasive breast cancer where:

    • A tumor of any size has spread into the chest wall or skin of the breast, causing swelling or an ulcer to develop.
    • Cancer cells may also be present in to up to nine axillary lymph nodes.
    • They may be present in lymph nodes by the breastbone.

    How Is The Stage Determined

    The staging system most often used for breast cancer is the American Joint Committee on Cancer TNM system. The most recent AJCC system, effective January 2018, has both clinical and pathologic staging systems for breast cancer:

    • The pathologic stage is determined by examining tissue removed during an operation.
    • Sometimes, if surgery is not possible right away or at all, the cancer will be given a clinical stage instead. This is based on the results of a physical exam, biopsy, and imaging tests. The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates, and may not predict the patients outlook as accurately as a pathologic stage.

    In both staging systems, 7 key pieces of information are used:

    • The extent of the tumor : How large is the cancer? Has it grown into nearby areas?
    • The spread to nearby lymph nodes : Has the cancer spread to nearby lymph nodes? If so, how many?
    • The spread to distant sites : Has the cancer spread to distant organs such as the lungs or liver?
    • Estrogen Receptor status: Does the cancer have the protein called an estrogen receptor?
    • Progesterone Receptor status: Does the cancer have the protein called a progesterone receptor?
    • HER2 status: Does the cancer make too much of a protein called HER2?
    • Grade of the cancer : How much do the cancer cells look like normal cells?

    In addition, Oncotype Dx® Recurrence Score results may also be considered in the stage in certain situations.

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    Stages Of Breast Cancer

    The stages of breast cancer range from 0 to IV .

    The highest stage is any cancer with metastases , no matter the size of the tumor, the lymph node status or other factors. This is known as metastatic breast cancer and is the most advanced stage of breast cancer.

    Most often, the higher the stage of the cancer, the poorer the prognosis will be.

    The table below lists the TNM classifications for each stage of breast cancer for people who have surgery as their first treatment.

    When TNM is
    IV

    *T1 includes T1mi.

    **N1 does not include N1mi. T1 N1mi M0 and T0 N1mi M0 cancers are included for prognostic staging with T1 N0 M0 cancers of the same prognostic factor status.

    ***N1 includes N1mi. T2, T3 and T4 cancers with N1mi are included for prognostic staging with T2 N1, T3 N1 and T4 N1, respectively.

    Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition published by Springer International Publishing.

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