Local/regional Treatment And Local Control
After primary CT, some programs have used surgical therapy alone, RT alone, or a combination of both treatments. Two prospective randomized trials have been reported in which surgery was compared with RT after primary CT. In both trials, surgery appeared to be equivalent to RT for local control and long-term survival . However, the local control rate in the studies was relatively low, in the 60%-70% range. In contrast, those phase II studies in which primary CT was followed by both surgery and RT have reported higher local control rates, in some cases reaching 85% . In our first two studies , the locoregional failure rate for stage IIB/IIIA and IIIB/regional IV were 7% and 26%, respectively .
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 You Might Feel
When breast cancer is advanced it can no longer be cured. But treatment can control it for some time and help to relieve symptoms.
Finding out that you cant be cured is distressing and can be a shock. Its common to feel uncertain and anxious. It’s normal to not be able to think about anything else.
Lots of information and support is available to you, your family, and friends. It can help to find out more about your cancer and the treatments you might have. Many people find that knowing more about their situation can make it easier to cope.
Talk to your doctor or nurse to understand:
- what your diagnosis means
- what is likely to happen
- what treatment is available
- how treatment can help you
You and your family will be looked after by a team of people who can provide you with support and information.
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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.
About Breast Cancer Staging And Grades
Staging means how big the cancer is and whether it has spread. Grading means how abnormal the cancer cells look under a microscope.
Doctors use the stage and grade of a cancer to help them decide which treatment you need.
There are different systems used in the UK to stage breast cancer. The most common one is the TNM system. Another is the number staging system.
Your doctor might also talk about early, locally advanced or secondary breast cancer.
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What Investigations Are Necessary For Staging Breast Cancer
Breast cancer staging almost always involves a bone scan, as breast cancer is highly prone to metastasize to the bones.
During this test, medics inject a small amount of a radioactive substance into the bloodstream, where it eventually collects in the bones. A radiation scanner is then able to detect accumulations of tracer substance in the bones.
If breast cancer spreads beyond the breast, 25% of the time it goes into bones first.
Dilemmas Of Stage Iv Breast Cancer
Indeed, there are many serious and personal questions involving stage IV breast cancer. So, overall survival is less likely, and gains from intensive breast cancer treatment are unfortunately rather modest. A serious consideration is, therefore, quality of life during the course of treatment.
These decisions tend to be a dynamic process, based on individual cases, between patients and physicians. Respect needs to be given to the expectations for treatment, the status of the disease and the patient wishes.
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Playing An Active Role
You play an active role in making treatment decisions by understanding your breast cancer diagnosis, your treatment options and possible side effects.
Together, you and your health care provider can choose treatments that fit your values and lifestyle.
The National Academy of Sciences released the report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis in 2013. Susan G. Komen® was one of 13 organizations that sponsored this study.
The report identified key ways to improve quality of care:
Stage Iii Breast Cancer Locally Advanced
A stage 3 breast cancer is sometimes referred to as a locally advanced breast cancer.
Stage III breast cancers are actually a heterogeneous group of cancers but account for about 7% of all initial breast cancer diagnosis.
Basically, a stage III breast cancer is one in which there is:-
- a primary tumor of greater than 5cm in diameter with no apparent metastasis
- OR the tumor is between 2cm and 5cm in diameter with evidence of rather significant metastasis.
Another way of looking at it is that stage III breast cancers either have a large but operable breast tumor . Or sometimes Stage III breast cancers present with a medium-size breast tumor which is more difficult to fully treat and cure with surgery alone.
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Drug Treatment Before Surgery
You might have chemotherapy as a first treatment to shrink the cancer down.
You might have hormone therapy first if your cancer cells have hormone receptors. But you usually only have this if chemotherapy isnt suitable.
If your cancer cells have particular proteins called HER2 receptors you might also have a targeted cancer drug called trastuzumab .
These treatments might shrink the tumour enough to allow your surgeon to remove just the area of cancer. This is called breast conserving surgery or a wide local excision.
If the cancer doesnt shrink enough, you need to have the whole breast removed . You may be able to have a new breast made . Do speak to your surgeon about this.
Before your surgery the lymph nodes in the armpit are checked for cancer cells.
You usually have radiotherapy to the breast after surgery.
How A Breast Cancers Stage Is Determined
Your pathology report will include information that is used to calculate the stage of the breast cancer that is, whether it is limited to one area in the breast, or it has spread to healthy tissues inside the breast or to other parts of the body. Your doctor will begin to determine this during surgery to remove the cancer and look at one or more of the underarm lymph nodes, which is where breast cancer tends to travel first. He or she also may order additional blood tests or imaging tests if there is reason to believe the cancer might have spread beyond the breast.
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Inoperable Breast Cancer Is Often Still Treatable
Stage 3C breast cancer is divided into operable and inoperable stage 3C breast cancer. However, the term inoperable is not the same as untreatable.
If your physician uses the word inoperable, it may simply mean that a simple surgery at this time would not be enough to get rid of all the breast cancer that is within the breast and the tissue around the breast. There must be healthy tissue at all of the margins of the breast when it is removed. Keep in mind that the breast tissue goes beyond the breast mound it goes up to the clavicle and down to a few inches below the breast mound. There must also be tissue to close the chest wound after the surgery is performed.
Another treatment method may be used first to shrink the breast cancer as much as possible before surgery is considered.
How Is Early/moderate Stage Breast Cancer Treated
Treatment for breast cancer depends on many factors, like your cancer stage, age, overall health, and testing results. If you have early or moderate stage breast cancer, your treatment may be different than someone who has advanced breast cancer. Your treatment may include some or all of the following:
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How Is Locally Advanced Breast Cancer Diagnosed
Locally Advanced breast cancers breast cancers may be large enough that it may be felt as a hard lump during a physical examination, or self-examination. However, these breast cancers may also be diagnosed through screening mammograms. An ultrasound may be necessary to further investigate the spread of disease.
A biopsy may be conducted to learn more about the tumour/s before treatment.
A CT, bone scan are usually also ordered to check that the cancer has not spread to other parts of the body.
M Categories For Breast Cancer
M followed by a 0 or 1 indicates whether the cancer has spread to distant organs — for example, the lungs, liver, or bones.
M0: No distant spread is found on x-rays or by physical exam.
cM0: Small numbers of cancer cells are found in blood or bone marrow , or tiny areas of cancer spread are found in lymph nodes away from the underarm, collarbone, or internal mammary areas.
M1: Cancer has spread to distant organs as seen on imaging tests or by physical exam, and/or a biopsy of one of these areas proves cancer has spread and is larger than 0.2mm.
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T Categories For Breast Cancer
T followed by a number from 0 to 4 describes the main tumor’s size and if it has spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ
T1 : Tumor is 2 cm or less across.
T2: Tumor is more than 2 cm but not more than 5 cm across.
T3: Tumor is more than 5 cm across.
T4 : Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.
Advanced Cancer That Progresses During Treatment
Treatment for advanced breast cancer can often shrink the cancer or slow its growth , but after a time, it tends to stop working. Further treatment options at this point depend on several factors, including previous treatments, where the cancer is located, a woman’s menopause status, general health, desire to continue getting treatment, and whether the hormone receptor status and HER2 status have changed on the cancer cells.
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Is Inoperable Breast Cancer Still Treatable
Although stage 3C breast cancer is defined as either operable or inoperable, an inoperable diagnosis doesnt necessarily mean that it cant be treated.
The term inoperable may mean that all the cancer in the breast and surrounding tissue cant be removed through simple surgery. When breast cancer is removed, a rim of healthy tissue around the tumor, called a margin, is also removed.
For breast cancer to be successfully removed, there needs to be healthy tissue in all margins of the breast, from your clavicle down to a few inches below the breast mound.
It is possible for inoperable breast cancer to become operable following a treatment to shrink the cancer.
What Is Stage 3 Breast Cancer
Also known as locally advanced breast cancer, the tumor in this stage of breast cancer is more than 2 inches in diameter across and the cancer is extensive in the underarm lymph nodes or has spread to other lymph nodes or tissues near the breast. Stage 3 breast cancer is a more advanced form of invasive breast cancer. At this stage, the cancer cells have usually not spread to more distant sites in the body, but they are present in several axillary lymph nodes. The tumor may also be quite large at this stage, possibly extending to the chest wall or the skin of the breast.
Stage 3 breast cancer is divided into three categories:
Stage 3A: One of the following is true:
- No tumor is found in the breast, but cancer is present in axillary lymph nodes that are attached to either other or other structures, or cancer may be found in the lymph nodes near the breast bone, or
- The tumor is 2 cm or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or other structures, or cancer may have spread to lymph nodes near the breastbone, or
- The tumor is 2 cm to 4 cm in size. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breast bone, or
- The tumor is larger than 5 cm. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.
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Conflict Of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The Associate Editor Daniel Grant Petereit declares that, despite having collaborated with author Silvia C. Formenti, the review process was handled objectively and no conflict of interest exists.
About Those Lymph Nodes
A surgeon will usually take a lymph node biopsy to determine if the breast cancer has spread to the axillary lymph nodes. This is not always necessary, however. A lymph node biopsy is not usually necessary for DCIS. However, for invasive breast cancer, yes, they do need to check the lymph nodes.
Sometimes, doctors will perform a sentinel node biopsy, rather than a full lymph node excisional biopsy if the concerns about cancer spread are minimal. Cancer cells tend to appear first in the sentinel node before spreading to the other nodes, or other areas of the body.
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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?
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.
New Approaches To Systemic Chemotherapy
As distant metastasis remains the major determinant of survival for patients with locally advanced breast cancer, new management approaches include the incorporation of novel chemotherapeutic agents, such as the taxanes, into combined-modality therapy and the use of dose-intensive chemotherapy
Incorporating New Agents
The proven activity of the taxanes docetaxel and paclitaxel in patients with advanced breast cancer, including women who have not responded to prior anthracycline therapy, has prompted various groups to investigate the potential role of taxanes administered either before or after surgery to patients with locally advanced breast cancer. The National Surgical Adjuvant Breast and Bowel Project is performing a study to evaluate whether patients with operable breast cancer who have received AC induction chemotherapy benefit from the addition of docetaxel before or after surgery. Other studies incorporating docetaxel as induction chemotherapy are now being designed.
The same Italian investigators have already reported preliminary data from a pilot study of doxorubicin/paclitaxel as induction chemotherapy in patients with locally advanced breast cancer that demonstrates the feasibility of this approach. Initial results are promising.
A feasibility study is also being conducted in the United States. It includes the incorporation of paclitaxel along with radiotherapy, then surgery, in patients with locally advanced breast cancer.
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