What Are The Stages Of Breast Cancer
When someone is diagnosed with breast cancer, doctors determine the stage of the disease which indicates how much cancer is in the body, whether it has spread beyond the breast, and, if so, how extensively. The stage of a cancer is often related to a patients prognosis and guides the treatment they receive.
Breast cancers are staged on a scale from zero to four. The lower the number, the less the cancer has spread.
- Stage 0 breast cancer is a non-invasive condition sometimes described as pre-cancerous. Stage 0 breast cancers include ductal carcinoma in situ and lobular carcinoma in situ . These diseases are not considered life-threatening, but can become invasive over time if not appropriately treated. Both increase the risk of developing breast cancer in the future.
- Stage I cancer usually involves a tumor that is two centimeters or smaller and has not spread outside the breast. Stage I cancers are almost always curable.
- Stage II and III cancer includes medium- to larger-sized tumors as well as tumors with positive lymph nodes. With advances in breast care treatment, stage II and stage III cancers are often curable, but many require additional treatments to achieve this goal.
- In Stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, or liver. Another name for Stage IV cancer is metastatic cancer.
Study Population And Clinical Endpoints
Eighty-six patients with MBC in whom WES analysis was performed and interpreted according to the Molecular Tumor Board of the Georges FranÃ§ois Leclerc Cancer Center were included in this single-center, retrospective study. Patients were enrolled between June 2018 and March 2020, and all received at least one line of platinum-based chemotherapy. Platinum chemotherapy was frequently associated with gemcitabine according to local practice.
Radiological response to platinum-based chemotherapy was determined locally, and assessed by clinical and radiological evaluations every 2-4 months for each patient. The Response Evaluation Criteria in Solid Tumors, version 1.1 , were used to assess treatment efficacy for measurable or evaluable lesions. Complete response was defined as the disappearance of all lesions. Partial response was defined as a decrease â¥30% over baseline in the sum of diameters of target lesions, and for non-measurable skin lesions by a clinical decrease in the size of lesions. Progression was defined as an increase â¥20% in the smallest sum of diameters as reference, or new clinical or radiological lesions. Stable disease was defined as no signs of progression or response, after 3 months of treatment. We also assessed disease control rate , which includes the percentage of patients with CR, PR and SD, and the objective response rate , which includes the percentage of patients with CR or PR.
What Is Stage Iii Breast Cancer
In stage III breast cancer, the cancer has spread further into the breast or the tumor is a larger size than earlier stages. It is divided into three subcategories.
Stage IIIA is based on one of the following:
- With or without a tumor in the breast, cancer is found in four to nine nearby lymph nodes.
- A breast tumor is larger than 50 millimeters, and the cancer has spread to between one and three nearby lymph nodes.
In stage IIIB, a tumor has spread to the chest wall behind the breast. In addition, these factors contribute to assigning this stage:
- Cancer may also have spread to the skin, causing swelling or inflammation.
- It may have broken through the skin, causing an ulcerated area or wound.
- It may have spread to as many as nine underarm lymph nodes or to nodes near the breastbone.
In stage IIIC, there may be a tumor of any size in the breast, or no tumor present at all. But either way, the cancer has spread to one of the following places:
- ten or more underarm lymph nodes
- lymph nodes near the collarbone
- some underarm lymph nodes and lymph nodes near the breastbone
- the skin
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What Is Stage Ii Breast Cancer
Stage II describes cancer that is in a limited region of the breast but has grown larger. It reflects how many lymph nodes may contain cancer cells. This stage is divided into two subcategories.
Stage IIA is based on one of the following:
- Either there is no tumor in the breast or there is a breast tumor up to 20 millimeters , plus cancer has spread to the lymph nodes under the arm.
- A tumor of 20 to 50 millimeters is present in the breast, but cancer has not spread to the lymph nodes.
Stage IIB is based on one of these criteria:
- A tumor of 20 to 50 millimeters is present in the breast, along with cancer that has spread to between one and three nearby lymph nodes.
- A tumor in the breast is larger than 50 millimeters, but cancer has not spread to any lymph nodes.
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 .
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.
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Other Factors That Can Affect A Cancer’s Stage
For some cancers, the values for T, N, and M arent the only things that determine the stage. Some other factors that may be taken into account include:
Grade: For most cancers, the grade is a measure of how abnormal the cancer cells look under the microscope. This is also called differentiation. Grade can be important because cancers with more abnormal-looking cells tend to grow and spread faster.
The grade is usually assigned a number, with lower numbers used for lower grade cancers.
- In low-grade cancers, the cancer cells look fairly normal. In general, these cancers tend to grow slowly and often have a better outlook.
- In high-grade cancers, the cancer cells look more abnormal. High-grade cancers often tend to grow quickly, so they may need different treatments than low-grade cancers.
Even when the grade doesnt affect a cancers stage, it might still affect a persons outlook and/or treatment.
Cell type: Cancers in some parts of the body can start in different types of cells. Because the type of cancer cell can affect treatment and outlook, it can be a factor in staging. For example, cancers of the esophagus are mainly either squamous cell cancers or adenocarcinomas. Squamous cell esophageal cancers are staged differently from esophageal adenocarcinomas.
A persons age: For some types of cancer, such as thyroid cancer, a persons age at the time of diagnosis can affect their outlook, so it is taken into account when assigning a stage.
Stage 3 Breast Cancer Treatment Options
Treatment for stage 3 breast cancers typically involves a combination of surgery along with chemotherapy to shrink the tumor before surgery and radiation after surgery to treat the chest wall and/or lymph nodes. Lymph nodes will also likely be removed during surgery.
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How Stages Are Determined
Stages of breast cancer are defined by a system called TNM:
- T stands for tumor. It describes the size and location of the main tumor.
- N stands forlymph nodes. It describes whether cancer has spread to the nodes. It also tells how many nodes have cancer cells.
- M stands formetastasis. It tells whether the cancer has spread to parts of the body away from the breast.
How Is Dcis Treated
DCIS may be treated with breast-conserving surgery, which is often followed by radiation therapy. With breast-conserving surgery, only the DCIS and some normal tissue around it is removed, and this type of surgery often does not alter the appearance of the breast significantly. Breast-conserving surgery may also be called a lumpectomy, a partial mastectomy, breast-sparing surgery, or segmental mastectomy.
DCIS can also be treated with single or double mastectomy, another type of surgery in which the whole breast is removed.
The goal of radiation therapy is to keep the DCIS from returning to the same breast, and research has shown that the risk of recurrence is substantially reduced by radiation therapy in some patients. Your radiation oncologist will take into account age, size of tumor, other medical problems and degree of differentiation in the cells before making a recommendation.. For patients with DCIS, radiation therapy would follow surgery. Radiation therapy can cause changes in the skin and increases the risk of developing secondary cancers in the future.
Patients may also have a recommendation for hormonal therapy. The goal is to decrease the likelihood of developing either further DCIS in or an invasive cancer.
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Breast Cancer Staging And Prognosis
Breast cancer staging describes how far the cancer has spread within the breast and other parts of the body. It is an important factor in making treatment decisions.
Breast cancer staging is based on tumour size, the extent that cancer has spread to other parts of the body and other clinical factors. Your doctor will assign a stage to your cancer after your physical exam, mammogram, and other diagnostic tests, such as a biopsy .
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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Stage 4 Breast Cancer
Stage 4 breast cancer is also known as secondary breast cancer.
Stage 4 breast cancer means:
- The tumour can be any size
- The lymph nodes may or may not contain cancer cells
- The cancer has spread to other parts of the body such as the bones, lungs, liver or brain
If your cancer is found in the lymph nodes under the arm but nowhere else in the body you do not have stage 4 breast cancer.
Breast Cancer Staging Process
Breast cancer staging is determined by how large tumors are, how far theyve spread, and other characteristics like the genetics of the tumor. Your cancer stage can be determined before surgery or after surgery .
Cancers clinical stage is determined through a physical exam, biopsy , and imaging tests. These imaging tests may include X-rays, computed tomography , positron-emission tomography , magnetic resonance imaging , or ultrasound.
After surgery, your breast cancer stage will either be confirmed or updated as a pathologic stage, using the features found and any additional information about how far cancer has spread gathered during surgery.
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How Is Hormone Receptorpositive Breast Cancer Treated
Hormone therapy either blocks the bodyâs ability to produce estrogen or progesterone, or interferes with the effects of hormones on breast cancer cells, which helps to slow or stop the growth of hormone-sensitive tumors.
Ovarian ablation, or treatment that stops or lowers the amount of estrogen made by the ovaries, can be done surgically, through radiation, or using drugs. With surgical treatment or radiation, the ovarian ablation is typically permanent. Suppressing ovarian function with drugs is temporary, and this group of medicines functions by interfering with signals from the pituitary gland stimulating the ovaries to produce estrogen. Side effects of ovarian suppression may include bone loss, mood swings, depression, and loss of libido.
Selective estrogen receptor modulators bind to estrogen receptors, preventing estrogen from binding. In addition to blocking estrogen activity, SERMs can also mimic estrogen effects because of their ability to bind. A SERM called tamoxifen, for example, blocks the effects of estrogen in breast tissue but acts like estrogen in the uterus and bone. Tamoxifen is effective in treating early-stage breast cancer after surgery. Some SERMs can treat advanced or metastatic breast cancer. Side effects of tamoxifen may include risk of blood clots, stroke, cataracts, endometrial and uterine cancers, bone loss in premenopausal women, mood swings, depression, and loss of libido.
Why Does Cancer Stage Matter
Staging helps your doctor plan the best treatment. This may include choosing a type of surgery and whether or not to use chemotherapy or radiation therapy. Knowing the cancer stage lets your entire health care team talk about your diagnosis in the same way.
Doctors can also use staging to:
Understand the chance that the cancer will come back or spread after the original treatment.
Help forecast the prognosis, which is the chance of recovery
Help determine which cancer clinical trials may be open to you.
See how well a treatment worked
Compare how well new treatments work among large groups of people with the same diagnosis
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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:
What Is The Recurrence Rate For Her2
- HER2-positive tumors tend to grow faster than tumors that do not express the HER2 protein. However, recurrence rates vary and depend upon more than simply the HER2 status of the tumor.
- Like other breast cancers, recurrence rates depend upon the extent of spread of the tumor at the time of diagnosis of the tumor along with other characteristics of the tumor.
- The development of anti-HER2 therapies has significantly improved the outlook for patients with HER2-positive breast cancer.
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Stage 1 Breast Cancer Treatment Options
Stage 1 breast cancers are usually treated with surgery to remove the mass, potentially with radiation therapy to treat the area.
Hormone therapies and chemotherapy can help reduce the risk that cancer will come back. Lymph nodes will also be biopsied or dissected to detect cancer.
Targeted therapies may also be used for HER2-positive stage 1 cancers.
Exams And Tests To Stage Cancer
Different types of exams and tests can be used to figure out a cancers stage.
- Depending on where the cancer is located, a physical exam may give some idea as to how much cancer there is.
- Imaging tests like x-rays, CT scans, MRIs, ultrasound, and PET scans may also give information about how much and where cancer is in the body.
- Endoscopy exams are sometimes used to look for cancer. For these exams, an endoscope, which is a thin, lighted tube is put inside the body to look for cancer.
- A biopsy often is needed to confirm a cancer diagnosis. Biopsies might also be needed to find out if a lump felt on an exam or if something seen on an imaging test in another part of the body is really from the spread of cancer. During a biopsy, the doctor removes a tumor or pieces of a tumor to be looked at in the lab. Some biopsies are done during surgery. But biopsies can also be done using a thin, hollow needle or through an endoscope. For more on biopsies, see Testing Biopsy and Cytology Specimens for Cancer.
- Lab tests of cancer cells and blood tests can also be used to help stage some types of cancer.
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