For information regarding breast cancer risk, prevention and family history, as well as screening mammography, ultrasound, and MRI, see Breast Problems.
“What Kind of Cancer Do I Have?”
This question might be answered in different ways. It seems that most women who ask this question are wanting to know if their cancer is one that “spreads like wildfire,” or one that can be cured with treatment. They want to know how aggressive their cancer is. When doctors talk about the kind of cancer someone has, they are usually talking about where cancer originated, and whether there is any indication of spread to other organs.
Here’s an analogy helpful to describe to those struggling with breast cancer with the concept of what kind of cancer they have. Imagine you’re a boxer who will be going out into the ring and are expected to fight an unknown opponent. You want to know if you’re going to be able to knock him out, or if the fight might go 15 rounds. You may have heard that they have a wicked left jab. One person might say that he is really quick on his feet. Someone else may know that he tires out in the later rounds.
Now, these details may make you feel better or worse about your odds in the ring, but they aren’t the most important. And none of these individual details are going to let you know in advance whether you are going to win the match, but each detail may add to your ability to prepare for the fight.
It’s the same with breast cancer and all the different details we can measure. Probably the most important things to know about the boxer would be his height and weight. With breast cancer, the opponent you’re fighting is cancer and the most important things are the sizes of cancer and whether there is cancer in the lymph nodes.
Biopsies
If you have had a biopsy of a lump in your breast, or a biopsy was done because of something is seen on a mammogram and the biopsy showed cancer cells, then you almost certainly have cancer that began in the breast. Although there are exceptions, most of these will be “breast cancer.” The pathologist almost always will be able to further classify the cells as being either of “ductal” or “lobular” origin, but both of these are still breast cancer. They will be able to see whether there is an invasion into the surrounding tissue or not. If there is no invasion, it will be called “in situ” or “non-invasive.” These cases are especially favorable because it’s like finding seeds which haven’t yet sprouted and surgical treatment is basically a cure.
If you have had a biopsy which showed one of the following, click on the appropriate link for more specific detailed information:
Atypical Ductal Hyperplasia, ADH, Atypical Lobular Hyperplasia, Lobular Carcinoma In Situ, LCIS, or Pre-Cancerous Cells
Scenario below contains information regarding situations in which a biopsy has been done, whether for a lump or other abnormality on exam, or for an abnormal mammogram, and the biopsy shows “abnormal cells” but does not show cancer.
I had a biopsy, and it showed one of the following— pre-cancerous cells, atypical ductal hyperplasia, ADH, atypical lobular hyperplasia, flat epithelial atypia (FEA), or lobular carcinoma in situ (LCIS). What should be done now?
The term “pre-cancerous cells” might be used for different situations. There are some benign cells that are more heaped up and irregular than normal breast cells, which are considered to be an indication that a woman is at higher risk for developing a cancer. There are a few such categories, atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), and atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS). Although these findings are not cancerous, the possibility of finding a tiny cancer nearby is high enough to consider a larger surgical excision of surrounding breast tissue, if these cell types are seen on a core needle biopsy. Though estimates vary, the possibility of finding a nearby hidden cancer in this case is probably about 10%.
The term “lobular carcinoma in situ” requires a little more explanation. Although the name includes the term carcinoma, lobular carcinoma in situ (LCIS) is not really cancer, but rather a noninvasive condition that increases the risk of developing cancer in the future. LCIS, also known as lobular neoplasia, occurs when abnormal cells accumulate in the breast lobules. Each breast has countless milk producing lobules, which are connected to the milk ducts. In LCIS, the abnormal cells are often found throughout the breast lobules, and both breasts are affected about 30 percent of the time.
Although we don’t think that LCIS itself becomes breast cancer, about 25 percent of patients who have LCIS will develop breast cancer at some point in their lifetime. (By way of comparison, for women in general, the risk of having breast cancer in their lifetime is about 12%.) This increased risk applies to both breasts, regardless of which breast is affected with LCIS, and in those who develop cancer, it may be either of the lobular or ductal type.
If any of these abnormal cell types are seen on a biopsy in which the sampling was done with some sort of needle (core biopsy, or stereotactic biopsy), in most cases a surgical excision should now be done, to get a larger sampling of tissue. In about 90% of cases, there will be nothing more significant seen, and no other treatment would be needed. But in about 10% of cases, some cancer “seeds”, or actual invasive cancer may be seen, which will require additional treatment.
This surgical excision can usually be done as an outpatient. Many surgeons still do what is called a “wire localization” procedure to help them know what breast tissue to remove. At DeKalb Surgical we rarely need to resort to this additional step, since our experience with ultrasonography allows us to more directly identify and remove the appropriate tissue. The use of ultrasound instead of a wire is much easier, simpler, and less expensive for the patient.
There is reason to consider taking a medication to prevent the development of cancer if you have had a biopsy showing these atypical cell types. This sort of treatment is called “chemoprevention”. There are two drugs available for this type of treatment, tamoxifen, and Evista. Studies have shown that by taking either of these drugs, once a day, for five years, that women at higher risk for developing breast cancer can decrease their risk by about half. Not all women choose this option, but it is important that you are at least aware of this option. Both drugs have a list of possible side effects, and one needs to balance the value of the potential benefit (decreased cancer risk) versus the risks (possibly experiencing one or more of the side effects).
Ductal Carcinoma In Situ (DCIS) or Non-Invasive Cancer
Scenario below contains information about cases in which a biopsy has been done, whether for a lump or other abnormality on exam, or for an abnormal mammogram, and the biopsy shows ductal carcinoma in situ (DCIS). This is different from “ductal carcinoma” or “invasive ductal carcinoma.”
I had a breast biopsy that showed ductal carcinoma in situ (DCIS). What should be done now?
Although no one ever wants to be told that they have cancer, the finding of ductal carcinoma in situ (DCIS) is one of those situations where we truly have found a cancer at a stage where it can be nipped in the bud. (In fact, some would even argue that it is not really a cancer “yet”, if it has not actually invaded into the surrounding tissue.) The “in situ” phrase means that we can tell for sure that these cells have the POTENTIAL to do their cancer thing (which means, to invade into surrounding tissue and eventually spread elsewhere), but that they have not yet invaded even the tissue right around the DCIS cells. You can think of these cells as “cancer seeds”, which haven’t yet sprouted, but have all the capability of doing so if left in place.
When DCIS is seen on a biopsy, you will usually need to have more tissue removed from your breast (usually the additional tissue removed is about the size of an ice cream scoop). This is almost always done as on open surgical excision in the operating room, either with sedation or general anesthesia, though sometimes under local anesthesia. This surgical excision is the most important treatment, and it is necessary to remove enough tissue so that none of the DCIS is seen along any of the margins of the removed tissue.
This is not always as simple as it might seem, because the DCIS can only be seen under the microscope, and the tissue is not usually examined under the microscope until after preserving the removed tissue in formalin overnight. This method gives more reliable information than trying to examine the tissue immediately (called a frozen section). This means that there are some women in whom the margins will show some more DCIS, and this will require another trip to the operating room to remove more tissue. This return to the operating room is necessary more often than you might think, as often as 50% of the time at some centers, whether here in Atlanta, or at an academic center. At DeKalb Surgical, this is only necessary about 10% of the time. I wish it would never happen, but sometimes even the non-invasive cancer cells can extend along the breast ducts in various directions. Obtaining clear margins is a matter of experience, compulsion with orientation of the tissue for the pathologist, and to some extent, how much additional breast tissue is removed.
In some cases, when the surgical excision is done, there may be some actual invasion seen in an adjacent area, that was not seen on the initial biopsy. In such cases, the situation changes a bit. In most cases of invasive cancer, even if only a tiny area, it is usually recommended to also surgically check some of the lymph nodes under your arm, to be sure there are no cancer cells seen there.
Although surgical excision for clear margins is the most important treatment for DCIS, radiation therapy AND 5 years of anti-hormonal therapy (with tamoxifen) is fairly standard additional treatment, with the intention of minimizing the possibility that you might ever develop another cancer in your breast. There is no need for chemotherapy in these very early stage cases. Your surgeon should discuss these issues with you in more detail. Probably the most important thing to remember if you have DCIS is that essentially all women are cured of their cancer when it is found at this stage.
You may wonder why radiation therapy and hormone-blocking treatment are recommended if all the DCIS is surgically removed. That’s a good question, and the answer comes from what we have learned over the past several decades of treating such patients. Studies have compared treatment with lumpectomy only versus lumpectomy plus giving radiation therapy, and also with or without giving hormone blocking treatment (tamoxifen). These studies showed that a higher percentage of patients who only had lumpectomy had cancer come back again over the following 5-10 years. And when the cancer comes back, sometimes it is invasive instead of non-invasive. After lumpectomy only, the recurrence rate is about 35%. If radiation therapy and tamoxifen are added, the recurrence risk is under 5%.
I like to think of the radiation therapy in this case as analogous to the weed preventive that you might apply to your yard in the spring. You might have had one sprig of crabgrass that you pulled out completely. You don’t see any other crabgrass in your yard, but you figure that it could pop up at a later date. The weed preventive will do just that—help prevent you from having more crabgrass in the future. In the same way, just removing the seeds of breast cancer (DCIS) might not be enough to keep some seeds sprouting and taking root elsewhere in your breast in the future. Radiation therapy decreases that risk considerably I most cases.
It is important to understand that the treatment of breast cancer, and DCIS, is evolving. Currently there is interest in trying to identify subsets of women for whom we feel the risk of invasive disease in the future is so low that we could avoid the usual radiation therapy and anti-hormonal therapy. Such treatment decisions can be individualized, and in your particular case, your priorities should certainly be considered in deciding on what treatment you ultimately received. Your priorities are given the uppermost consideration at DeKalb Surgical in formulating an individualized treatment plan.
Invasive or Infiltrating Breast Cancer, Invasive Ductal Cancer, Invasive Lobular Cancer, Invasive Mammary Cancer
The scenarios below regard cases in which a biopsy has been done, whether for a lump or other abnormality on an exam, or for an abnormal mammogram, and the biopsy shows invasive cancer. This general information should be helpful for patients with all different “stages” of breast cancer, or if you do not know what stage your cancer is.
I had a breast biopsy that showed invasive cancer. What should be done now?
You will need to be evaluated to decide on an individualized treatment plan, based on the specific details of your case. Several factors must be considered, including the type of breast cancer (ductal is the most common subtype, and lobular is the other, but there are even subtypes of the subtypes), your age and menopausal status, the apparent size of the tumor, your medical history, and any pertinent abnormalities noted on a thorough physical exam, findings on mammogram and possibly additional imaging studies, and some molecular characteristics of the cancer (you might think of these as the “fingerprint” of the cancer), primarily the estrogen receptor (ER) and HER2 status. For some women, an additional assay called the OncotypeDX Recurrence Score may be ordered as well.
All these elements should be considered by your surgeon. In cases where cancer appears small, and there is no evidence of cancer spread to lymph nodes or elsewhere, the next treatment step is surgery. This will usually mean a “lumpectomy and sentinel lymph node biopsy”. A “lumpectomy”, which can also be referred to as a “partial mastectomy”, removes enough tissue around cancer so that no cancer cells are seen along the margins of the removed tissue. I like to use the analogy of a hard-boiled egg. The yellow yolk (which represents cancer) on the inside should have “egg white”, or normal breast tissue, on all sides, such that that yellow egg yolk is not seen anywhere on the outside surfaces of the egg. Now in actuality, cancer cells aren’t yellow like an egg yolk, and one cannot always tell during the surgery that the margins are clear. But fortunately, in over 90% of the cases at DeKalb Surgical, the margins are clear with just one procedure. At many centers, as many as 40-50% of women need a second procedure to get “clear margins”.
The “sentinel node biopsy” part of the operation involves a second small incision under your arm (called the axilla), combined with an injection of dye in your breast, usually at the nipple. The idea is to check to see if there is any cancer spread to the lymph nodes. The dye injection allows the surgeon to identify the first nodes to receive any lymph flow from the breast; if any cancer cells have spread to the lymph nodes, they almost certainly will be found in these first, or sentinel, nodes. This method allows the surgeon to leave all of the other lymph nodes alone unless cancer cells are seen in the sentinel nodes.
Following lumpectomy, radiation is almost always required in order to minimize the possibility of recurrence. Decades ago, when mastectomy was the only surgical option, several national and international studies were done to determine if women could undergo a less radical operation. Although these studies clearly showed that women did just as well long term with lumpectomy instead of mastectomy, radiation therapy was needed to keep the local recurrence rate to a minimum. In these studies, women who had lumpectomy without radiation therapy had cancer come back in the breast about 30% of the time. And so, these days when a lumpectomy is considered the preferred surgical option, it is almost always considered as part of a “package deal”, with radiation therapy to follow.
Radiation therapy for breast cancer has traditionally been given as several daily brief treatments to the entire breast, usually taking about 6 weeks. It is given this way in order to minimize the side effects of the skin. The effect of the radiation on the breast tissue is “cumulative”, meaning that the total required dose can be divided into very small daily doses, and as long as the sum of the small doses equals the required total dose, you will achieve the desired outcome. If higher daily doses would be given instead, the skin would get radiation burns. Even with the small doses given, this can sometimes be a problem. The radiation therapy physician will discuss these possibilities with you and will monitor you for any evidence of problems during the six weeks of treatment.
There is a new way to give the radiation therapy after lumpectomy, which is an option for some women, called partial breast irradiation therapy. This method can be completed in just 5 days, with two daily treatments each day. The radiation is given by placing a tiny “radioactive seed” inside the breast briefly for each treatment. This method almost completely eliminates the risk of skin damage, and this is why the treatment can be completed so much faster. This technique has been used at DeKalb Surgical since 2006 for selected women, so we have lots of experience with it.
For cancers that are larger, and for cancers that have already spread to lymph nodes or elsewhere in the body, surgery sometimes is delayed until after completion of some chemotherapy. This portion of the treatment (called neoadjuvant therapy) is managed by a medical oncologist and not the surgeon. Modern treatment of breast cancer involves a team of specialists to customize your care, based on the unique characteristics of each individual case. This team includes the surgeon, the oncologist, radiation therapist, and often others, such as the plastic surgeon, physical therapist, geneticist, nutritionist, clinical trials specialists, as well as others, depending on your specific needs.
In some cases, it may be best to undergo chemotherapy first, to shrink down the tumor, and then follow with the surgery to remove any remaining cancer cells. An advantage of this sequence is that we can see that in your specific case, the selected chemotherapy is effective, since we will be able to see that cancer, if it’s palpable, actually shrinks during treatment. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL remaining cancer has disappeared. These patients have a particularly good prognosis.
At DeKalb Surgical, we have available many clinical trials for patients with breast cancer. Clinical trials allow us to offer tomorrow’s breast cancer treatments today. These trials often include newly approved drugs, which have shown benefit in more advanced breast cancers, and now are being tested in women with breast cancers that are more contained (ie, a lower stage). Or they may be testing a less radical method of giving the usual radiation therapy to the breast after surgery. Other trials are intended to show that hormonal treatment (which is much easier to tolerate compared to chemotherapy) is effective in shrinking tumors before surgery. Not all women are candidates for clinical trials, but studies have shown that women who participate in clinical trials tend to have better outcomes than those who don’t go on a trial.
If you already have been told what stage your cancer is, click on the appropriate stage below for more information. We categorize breast cancer based on a number of different characteristics, but some characteristics have more significance than others. Three of the most important characteristics are the size of cancer in the breast (referred to as “T” for tumor), whether there is any cancer spread into the nearby lymph nodes (referred to as “N” for nodes), and whether there is any spread to other parts of the body (referred to as “M” for metastasis). The stage of your cancer is derived by considering only these three characteristics. Although the stage of the cancer is very important, the recent advances in breast cancer treatment have made other characteristics equally important, including estrogen receptor status (ER), HER2 status, and for some cancers, OncotypeDX Recurrence Score. These are not considered in determining the stage but are extremely important in deciding on the best treatment.
I don’t know what stage my cancer is.
If you have had a biopsy and already know that it’s cancer, but don’t know the stage, you can ask your doctor. Most cancers when diagnosed are in the Stage 0, 1, or 2 categories. Each stage has certain specific treatment options appropriate for that category of cancers, as you will see in the paragraphs above.
If your doctor seems unable to tell you what stage your cancer is, you may want to consider seeing us for a second opinion. Making an assessment of the stage of your cancer is critical in deciding on appropriate treatment.
Your doctor will make an estimate about the size of cancer based on the available information at the time of biopsy. If it is an actual lump, an estimate of its size can be made just by feeling it (palpation). Such cancers can usually be seen with an ultrasound machine, and if so, a more accurate measurement can usually be made this way. If your cancer was found because of calcifications on a mammogram, the size is usually harder to estimate before surgery, though these usually are quite small if they cannot be felt, so that’s usually a good sign. Your doctor should also check to see if any lymph nodes can be felt under your arm. This is sometimes an indication that some cancer cells have already spread from the breast itself. An ultrasound machine can also be used to evaluate the lymph nodes, and abnormal nodes may be seen even if they cannot be felt. If necessary, a biopsy of the lymph nodes can be done with a needle, usually with the aid of an ultrasound in order to precisely position the needle in the node.
The pathologist can provide an estimate of the aggressiveness of cancer, based on how abnormal in appearance the cancer cells are. This is called grading cancer. Tumor Grade is not the same as tumor Stage. The grade can be either 1, 2, or 3. Compared to Grade 1 cancers, the Grade 3 cancers are considered to be the more aggressive type, are more bizarre in appearance, and show evidence of dividing more rapidly.
There are some additional tests routinely ordered for evaluating breast cancer cells, but these usually take a week or so to be completed. The cells can be analyzed to see if there is any sensitivity to hormones, specifically estrogen and progesterone, the two most significant female hormones. Another test checks to see if there is an extra production of a protein called HER2. This protein is involved in the growth of breast cancer cells, and patients with “HER2 positive” cancers are more likely to have recurrence or spread of their cancer. Although the prognosis is poorer for these HER2 + patients as a group, we now have two HER2 specific chemotherapy drugs (Herceptin, or trastuzumab, and Perjeta, or pertuzumab) that specifically target the HER2 receptor protein, and are highly effective in such cases.
The OncotypeDX Recurrence Score is another test used for cancers that are specifically estrogen receptor (ER) positive and HER2 negative. This test takes about 10-14 days to get a result. This test should only be ordered if the result is going to be used in deciding on the use of chemotherapy.
These are not the only tests available for analyzing your breast cancer, but these are the most important ones. There is no doubt that ongoing research will find new tests which will help in deciding on the best treatment. It is hoped that, just as Herceptin and Perjeta specifically target HER2, and tamoxifen targets the estrogen receptor, we may find other specific cancer proteins which can be targeted with specifically designed antibody drugs.
| Tests & Categories | Description | How Result is Used |
|---|---|---|
| Tumor size | Measured in centimeters, with ranges of :no invasion (T0), 0-2 cm (T1), 2-5 cm(T2), and >5 cm (T3), or more advanced based on type of spread (T4) | The stage of the cancer is based in part on tumor size, with stages ranging from 0-4. This is the “T” in TNM staging. |
| Any tumor found in the lymph nodes? | Measured as positive or negative, or 0, 1-3, >3 | The stage of the cancer is based in part on lymph node status, with stages ranging from 0-4. This is the “N” in TNM staging. |
| Any tumor seen elsewhere (metastatic disease), for example in the lungs, bones, liver, or brain? | Measured as “yes” (M1) or “no” (M0) | The stage of the cancer is based in part on the presence or absence of cancer elsewhere (metastases), with stages ranging from 0-4. This is the “M” in TNM staging. |
| Grade | 1, 2, or 3 | Grade 3 is more aggressive, though this factor is of slightly less significance than the cancer stage. |
| Estrogen receptor (ER) | Usually measured as a percentage, 0-100%. “Positive” is defined differently by various labs, as >1%, >5%, or >10%. | If ER positive, treatment that either blocks estrogen, or decreases its production is likely to be effective in decreasing risk of recurrence. |
| Progesterone receptor (PR) | Usually measured as a percentage, 0-100%. “Positive” is defined differently by various labs, as >1%, >5%, or >10%. | If positive, prognosis is better, though specific targeted treatment options are not available. |
| HER2, or HER-2-neu | Two different ways to measure, either by measuring the actual amount of the protein receptor (HercepTest), or by measuring if there are extra copies of the gene that produces the protein (FISH). For HercepTest, “negative” is defined as 0, or 1+. “Positive” is defined as 3+. A 2+ result is considered equivocal, and in these cases, the other (FISH) test is usually ordered to decide if positive or negative. FISH “negative” is defined as 1-1.8, “positive” is defined as >2.2, and 1.8-2.2 is also considered equivocal. | If positive, the cancer is considered more aggressive, but a specific targeted treatment (Herceptin) is available, and is routinely used except perhaps in very small localized tumors. |
| Ki-67 | Given as a percentage from 0-99%, corresponding to the “proliferative” ability of the cancer cells. | Higher percentage implies a more aggressive cancer, but has less significance than cancer stage. |
| OncoTypeDX Recurrence Score | Result is a number from 1-99; Interpretation varies for premenopausal versus postmenopausal, and whether there is cancer in the lymph nodes. This test is only used in cancers that are estrogen receptor (ER) positive and HER2 negative. | If Recurrence Score is low, then there is no benefit from taking chemotherapy. If Recurrence Score is high, there a BIG advantage to taking chemotherapy. . |
OncotypeDX Recurrence Score
OncotypeDX is a molecular test available that helps women and their doctors in predicting their risk for recurrence and to determine if their cancer will respond to chemotherapy. OncotypeDX is performed on tissue from the initial biopsy or lumpectomy specimen. It uses the unique genetic profile of each woman’s breast cancer to make an accurate prediction about whether cancer will recur. It measures an array of genes that are known to be associated with more aggressive tumors. The test has been shown to be much more powerful than current predictive methods, which are based on “clinical staging”, which is based on the size of the tumor and the status of the lymph nodes.
This OncotypeDX test was initially studied in a large group of women who had participated in two large national breast cancer clinical trials through the National Surgical Adjuvant Breast and Bowel Project (NSABP) several years ago. All of these women had early-stage breast cancer at diagnosis, and all were treated in a similar fashion, with tamoxifen. The OncotypeDX test was performed on the initial tissue specimens for all these women. The women were then grouped according to the OncotypeDX test results. All women had been followed for at least 10 years, so it was known who had recurrent cancer.
For the group as a whole, there were 15% who had a recurrence within the first ten years after diagnosis. Using the OncotypeDX test, this group could be split into 3 sub-groups, one whose recurrence risk was extremely low, at 7%, a second group with an intermediate risk, and a third group whose recurrence risk was quite high, at 31%, despite being classified as “early stage” by clinical criteria. About half of the women were in the low recurrence risk group. The researchers concluded that the test is highly prognostic for this group of breast cancer patients, independent of treatment.
The test was also studied to see if it could predict who would benefit from receiving chemotherapy. Previously, many women with early-stage breast cancer were advised to receive chemotherapy, in a “one size fits all” fashion, even though only a very small number are actually going to benefit. Based on clinical staging, there is no simple way to decide which women would not benefit from chemotherapy. In other words, we were overtreating many women with chemotherapy, for lack of being able to distinguish which women would actually benefit.
Using the OncotypeDX test, 50% of the women, all with a low Recurrence Score, had no benefit from receiving chemotherapy. Stated another way, if the Recurrence Score is low, the risk of recurrence is extremely low, and receiving chemotherapy makes no difference in the outcome. On the other hand, in the remaining 50% of women with a higher recurrence score, there a much more dramatic benefit from receiving chemotherapy. Incorporation of this test into the decision process allows the doctor to individualize treatment based on the “fingerprint” of the patient’s cancer. Approximately 50% of women with early breast cancer can thus avoid the toxicity that comes with receiving chemotherapy.
This initial study was reported at the annual San Antonio Breast Cancer Symposium held in December 2004 and subsequently published in the New England Journal of Medicine. The test has since been studied in women with more advanced breast cancer, those in which the cancer has already spread to the lymph nodes and has shown similar success in identifying a large percentage of women who don’t need chemotherapy. The test is only indicated for patients with breast cancer that is “positive” for estrogen receptors (ER), and “negative” for HER2.
Stages
The method of staging cancers has been well-defined for decades. There is a standard manual that has been agreed upon by virtually the entire international community of cancer experts, which is used as a reference. This manual is updated every few years. The idea is to try to categorize cancers into smaller groups that are likely to behave in similar fashion. This grouping of similar cancers allows doctors to provide more individualized treatment plans.
Rather than treating all cancers the same, each stage may be treated in a way that will best fit that subgroup of cancers. The concept of staging is essential in making the best decisions about treatment. Your surgeon should determine the stage of your cancer at the outset, based on what can be learned about your cancer from physical examination, from biopsy information, and from any imaging studies that might have been done. This is called a clinical stage.
Once a definitive operation has been done, the added information from the surgery will then be used to revise the cancer stage if needed. This is called a pathologic stage. Now, how does the staging system work? For nearly all different cancer types, the stage depends on just three things, summarized by the initials TNM. These stand for: (1) T is for tumor size, (2) N is for lymph node status, and (3) M stands for evidence of metastatic disease, or in other words, cancer spread beyond the lymph nodes. Not surprisingly, this is called the TNM staging system. The group which publishes the guidelines is called the American Joint Committee on Cancer.
Stage 0 Breast Cancer (DCIS, or Ductal Carcinoma in Situ, or Intraductal Cancer)
Although no one ever wants to be told that they have cancer, the finding of ductal carcinoma in situ (DCIS) is one of those situations where we truly have found a cancer at a stage where it can be nipped in the bud. (In fact, some would even argue that it is not really a cancer “yet”, if it has not actually invaded into the surrounding tissue.) The “in situ” phrase means that we can tell for sure that these cells have the POTENTIAL to do their cancer thing (which means, to invade into surrounding tissue and eventually spread elsewhere), but that they have not yet invaded even the tissue right around the DCIS cells. You can think of these cells as “cancer seeds”, which haven’t yet sprouted, but have all the capability of doing so if left in place.
When DCIS is seen on a biopsy, you will usually need to have more tissue removed from your breast (usually the additional tissue removed is about the size of an ice cream scoop). This is almost always done as on open surgical excision in the operating room, either with sedation or general anesthesia, though sometimes under local anesthesia. This surgical excision is the most important treatment, and it is necessary to remove enough tissue so that none of the DCIS is seen along any of the margins of the removed tissue.
This is not always as simple as it might seem, because the DCIS can only be seen under the microscope, and the tissue is not usually examined under the microscope until after preserving the removed tissue in formalin overnight. This method gives more reliable information than trying to examine the tissue immediately (called a frozen section). This means that there are some women in whom the margins will show some more DCIS, and this will require another trip to the operating room to remove more tissue. This return to the operating room is necessary more often than you might think, as often as 50% of the time at some centers. At DeKalb Surgical, this is only necessary about 10% of the time. We wish it would never happen, but sometimes even the non-invasive cancer cells can extend along the breast ducts in various directions. Obtaining clear margins is a matter of experience, compulsion with orientation of the tissue for the pathologist, and to some extent, how much additional breast tissue is removed.
In some cases, when the surgical excision is done, there may be some actual invasion seen in an adjacent area, not removed with the initial needle biopsy. In such cases, the situation changes a bit. In most cases of invasive cancer, even if only a tiny area, it is usually recommended to also surgically check some of the lymph nodes under your arm, to be sure there are no cancer cells seen there. You will find more information about this on the invasive cancer page.
Although surgical excision for clear margins is the most important treatment for DCIS, radiation therapy AND 5 years of anti-hormonal therapy (usually with tamoxifen) is fairly standard additional treatment, with the intention of minimizing the possibility that you might ever develop another cancer in your breast. There is no need for chemotherapy in these very early stage cases. Your surgeon should discuss these issues with you in more detail. Probably the most important thing to remember if you have DCIS is that essentially all women are cured of their cancer when it is found at this stage.
Stage 1 (Invasive) Breast Cancer
If your cancer is a (clinical) Stage 1, it means that the tumor in your breast appears small (less than 2 cm, which is about ¾”) and that there is no evidence of spread into the lymph nodes under your arm (axilla), or anywhere else in your body. Using the TNM staging, the possible combinations within stage 1 are
- Stage IA: T1, N0, M0
- Stage IB: T0 or T1, N1mi, M0
Your doctors use their best estimate about the tumor size and the presence of cancer in lymph nodes or elsewhere to come up with the “clinical” stage, in order to make appropriate treatment plans prior to the surgery. Once the surgery has been done, these estimates are re-evaluated, based on actually looking at these tissues under the microscope. So the clinically estimated stage may change based on the “pathologic” findings.
Treatment usually includes surgery first, and there will usually be plans for radiation therapy for the breast as well. Your doctor will determine whether any other treatments, such as hormone-blocking treatment, or chemotherapy, should be added, depending on some other test results. More about this below.
The standard surgical treatment is usually a “lumpectomy” (also called “partial mastectomy”), and a “sentinel lymph node biopsy”. Other terms that might be used are “breast-conserving surgery”, or “breast conservation”.
A lumpectomy removes enough tissue around cancer so that no cancer cells are seen along the margins of the removed tissue. One good analogy to explain this is to think of your breast with the cancer in it as a quart of ice cream with a nut somewhere inside. Doing the surgery is similar to scooping out some of the ice cream with the nut inside. The nut (which represents cancer) on the inside should have ice cream, or normal breast tissue, on all sides, such that that nut is not seen anywhere on the outside surfaces of the scoop. Now in actuality, cancer cells aren’t dark or hard like a nut, and one cannot always tell during the surgery that the margins are clear. But fortunately, in over 90% of the cases at DeKalb Surgical, the margins are clear with just one procedure. At many centers, as many as 30-40% of women need a second procedure to get “clear margins”.
The “sentinel node biopsy” part of the operation involves a second small incision under your arm (called the axilla), combined with an injection of dye in your breast, usually at the nipple. The idea is to check to see if there is any cancer spread to the lymph nodes. The dye injection allows the surgeon to identify the first nodes to receive any lymph flow from the breast; if any cancer cells have spread to the lymph nodes, they almost certainly will be found in these first, or sentinel, nodes. This method minimizes the risk for developing some arm swelling, called “lymphedema” as a result of disrupting the lymphatic system.
Following lumpectomy, radiation is usually required in order to minimize the possibility of recurrence. Decades ago, when mastectomy was the only surgical option, several national and international studies were done to determine if women could undergo a less radical operation. Although these studies clearly showed that women did just as well long term with lumpectomy instead of mastectomy, radiation therapy was needed to keep the local recurrence rate to a minimum. In these studies, women who had lumpectomy without radiation therapy had cancer come back in the breast about 30% of the time. And so, these days when a lumpectomy is considered the preferred surgical option, it is usually considered as part of a “package deal”, with radiation therapy to follow.
Radiation therapy for breast cancer has traditionally been given as several daily brief treatments to the entire breast, usually taking about 4 weeks. It is given this way in order to minimize the side effects of the skin. The effect of the radiation on the breast tissue is “cumulative”, meaning that the total required dose can be divided into very small daily doses, and as long as the sum of the small doses equals the required total dose, you will achieve the desired outcome. If higher daily doses would be given instead, the skin would get radiation burns. Even with the small doses given, this can sometimes be a problem. The radiation therapy physician will discuss these possibilities with you and will monitor you for any evidence of problems during the six weeks of treatment.
There is another way to give the radiation therapy after lumpectomy, which is an option for some women, called partial breast irradiation therapy. This method can be completed in just 3-5 days, with one or two treatments each day. The radiation is given by placing a tiny “radioactive seed” inside the breast briefly for each treatment. This method almost completely eliminates the risk of skin damage, and this is why the treatment can be completed so much faster. This technique has been used at DeKalb Surgical since 2006 for selected women, so we have lots of experience with it. You can read more about this treatment option.
Many years ago, the standard treatment for all women with breast cancer was a mastectomy. This was because over a hundred years ago when most women with breast cancer were dying, a radical mastectomy was the very first treatment discovered to give women a chance. Building on that first treatment option, surgeons through the years gradually tested less radical surgical procedures. In parallel, women began discovering their breast cancers at earlier stages, such that less radical procedures were more easily applied. About 50 years ago, studies that compared breast conservation finally were being published. Surgeons and women were actually initially reluctant to consider this option. That is less of an issue these days, as most women are very much in favor of keeping their breast if possible, and this indeed usually is.
A mastectomy is still an option instead of breast conservation, and there are a number of reasons why a woman or her surgeon may choose this alternative. Some women, in our experience, may prefer the “simplicity” of a mastectomy, in that it usually eliminates the need to have radiation therapy to the breast after surgery. If a woman has had previous cancer treated in the same breast, with lumpectomy and radiation, a repeat breast-conserving procedure is not usually recommended. If a woman tests positive for one of the BRCA genes, the much higher risk of having more breast cancer in the future usually steers your surgeon to recommending, not just mastectomy, but bilateral mastectomy. If there are extensive calcifications seen in your breast on mammography, mastectomy may be preferred as well. Some women have more than one cancer in the breast at the time of initial diagnosis, and in these cases a mastectomy may be recommended. In some unusual cases, a woman cannot receive the necessary radiation therapy after surgery, and in these cases, a mastectomy will usually be necessary (one example of this is for women who have scleroderma). Some women have what might be called “cancerphobia”, and no amount of discussion or reasoning or logic will dissuade them from wanting a mastectomy. In most cases, your surgeon should be offering breast conservation, unless it is made very clear why it would not be appropriate.
If you do have a mastectomy, in most cases, a breast reconstruction is an option. In many cases, this can be done immediately. In other words, you have your surgery for the mastectomy, and you wake up afterward with the reconstructed breast. Not all women choose to undergo breast reconstruction or may choose to delay the reconstruction until a later date. The discussion about what is best for you can get a bit complicated and is best done with your surgeon and plastic surgeon. There are many options available these days, including the use of some tissue from other adjacent parts of your body, silastic or saline implants, or a combination of these. Surgeons may leave the skin “envelope” of your breast (a “skin-sparing mastectomy”), and then re-fill the skin with the transferred tissue or with an implant. This method seems to give better cosmetic results in general.
It is important to know that if radiation therapy is necessary, it can affect the cosmetic results of a reconstruction, so if you are going to need radiation even after a mastectomy, your doctors should discuss the possible added risks.
Your cancer tissue will be tested for any sensitivity to hormones. The two routine tests are “estrogen receptor (ER)” and “progesterone receptor (PR)”. The ER is considered the more important one, but basically, if either or both of these is “positive (+)”, then it means the cancer cells can be stimulated by estrogen. There are a number of drugs which can block the effects of estrogen on any cancer cells remaining in the body, and so one of these drugs is routinely used for ER+ cancers. But these drugs might blunt the effectiveness of chemotherapy or radiation therapy if they are given at the same time. For this reason, any hormone blocking treatment is usually held until after the other treatments (surgery, radiation therapy, chemotherapy) are completed. The estrogen-blocking drugs include tamoxifen, Arimidex (anatrozole), Femara (letrozole), and Aromasin (exemestane). Tamoxifen works differently from the other three, by blocking the receptors for estrogen on the breast cells. The other three are all in the class of drugs called “aromatase inhibitors”. These act by blocking the production of estrogen in the body. An important thing to understand about these drugs is that they do not inhibit the production of estrogen in functional ovaries. For this reason, aromatase inhibitors are not effective in women before menopause. And so, for women who have not yet gone through menopause, tamoxifen is the only tried and true option for hormone-blocking treatment in ER+ women.
In Stage 1 breast cancer, the likelihood of cancer coming back after initial treatment is fairly low. And so, some of the weapons we have to fight breast cancer might not always be necessary. On the other hand, there is almost always at least some small chance that cancer may come back in the future. This uncertainty is what makes it hard to decide when to use “everything we’ve got”, which usually boils down to whether to add chemotherapy to the treatment plan. Fortunately, we have several tools to help us decide with each individual patient what is the best plan. This may include chemotherapy in some cases; for young women, this will more often be the case, especially if your cancer does not show sensitivity to hormones, or if cancer shows sensitivity to a specific chemotherapy drug, like Herceptin.
The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three-week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.
One routine assay done on breast cancers is called the HER2 assay. We have learned that when this gene is “overexpressed” in cancer, it is more likely to act aggressively, by spreading to other organs. But we have also discovered some drugs, which are specifically designed to block this protein’s function and they are very effective at decreasing the aggressiveness of these cancers. Only about 15% of breast cancers have this genetic dysfunction, but if your cancer is “HER2 positive”, you likely will be advised to receive these specific chemotherapy agents, called Herceptin (trastuzumab) and Perjeta (pertuzumab), in addition to some other drugs. The Herceptin is usually given in cycles over the entire first year following the initial treatment.
You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website. There is a direct link to their online “virtual book” for with Stage I or II breast cancer.
Stage 2 (Invasive) Breast Cancer
If your cancer is a (clinical) Stage 2, it means that the tumor in your breast is a bit larger, or that there are between 1-3 lymph nodes with cancer in them, even though the tumor in your breast is still small. There is no evidence of disease spread to organs beyond the breast and the lymph nodes. Using the TNM staging, the possible combinations within stage 2 are:
- Stage IIA: T0 or T1, N1 (but not N1mi), M0 / T2, N0, M0
- Stage IIB: T2, N1, M0 / T3, N0, M0
Your doctors use their best estimate about the tumor size and the presence of cancer in lymph nodes or elsewhere to come up with the “clinical” stage, in order to make appropriate treatment plans prior to the surgery. Once the surgery has been done, these estimates are re-evaluated, based on actually looking at these tissues under the microscope. So the clinically estimated stage may change based on the “pathologic” findings.
As you might expect, the possibility of cancer coming back after treatment is higher for Stage 2 cancers than for Stage 1 cancers. But the prognosis is still good. The treatment usually includes surgery, chemotherapy, and radiation therapy.
One of the first decisions your surgeon will need to make with you is whether to plan the surgery first, or whether to consider giving you chemotherapy first. Many women are not aware that there are lots of reasons to consider delaying the surgery until after chemotherapy; I’ll explain this in more detail below. I would say though, that in general, if there is enough information at diagnosis to know that chemotherapy will be included in the treatment, it may be preferable to use chemotherapy first, and then do the surgery.
In addition to the clinical stage, your doctors will consider the following factors in making a treatment plan: your age, your personal and family history of other breast cancers, sensitivity of your cancer to estrogen, whether your cancer has “overexpression” of HER2, findings on your mammogram, and possibly some other imaging studies as well, and your overall health, paying particular attention to any heart or lung diseases. There may be other factors of importance in individual cases. Since all of these factors can affect the final recommendations, it is difficult to summarize the treatment possibilities here.
Surgery plays an important role in Stage 2 breast cancer, although chemotherapy needs to be considered in most cases as well. With these more advanced cancers, the order of treatment more often begins with chemotherapy. The DeKalb Surgical doctors typically support the use of chemotherapy before surgery. This method allows us to see that in your individual case, the selected chemotherapy is effective in shrinking the tumor down in size. Not only does this let us know with certainty that your cancer is sensitive to the selected treatment, the shrinking tumor makes it easier to surgically remove it with clear margins later on. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL remaining cancer has disappeared. These patients have a particularly good prognosis.
Lumpectomy, also called “partial mastectomy” can usually be considered instead of mastectomy for Stage 2 breast cancer. Other terms that might be used are “breast-conserving surgery”, or “breast conservation”. As long as we can get “clear margins” around cancer then a mastectomy is not needed. Since the Stage 2 category includes larger tumors than those in the Stage 1 category, more women in this group may need a mastectomy, but it’s important to know that lumpectomy is still likely to be possible, particularly if chemotherapy is given first, and there is a good “response” to this treatment, with a decrease in tumor size.
A lumpectomy removes enough tissue around cancer so that no cancer cells are seen along the margins of the removed tissue. One good analogy to explain this is to think of your breast with the cancer in it as a quart of ice cream with a nut somewhere inside. Doing the surgery is similar to scooping out some of the ice cream with the nut inside. The nut (which represents cancer) on the inside should have ice cream, or normal breast tissue, on all sides, such that that nut is not seen anywhere on the outside surfaces of the scoop. Now in actuality, cancer cells aren’t dark or hard like a nut, and one cannot always tell during the surgery that the margins are clear. But fortunately, in over 90% of the cases at DeKalb Surgical, the margins are clear with just one procedure. At many centers, as many as 30-40% of women need a second procedure to get “clear margins”.
The “sentinel node biopsy” part of the operation involves a second small incision under your arm (called the axilla), combined with an injection of dye in your breast, usually at the nipple. The idea is to check to see if there is any cancer spread to the lymph nodes. The dye injection allows the surgeon to identify the first nodes to receive any lymph flow from the breast; if any cancer cells have spread to the lymph nodes, they almost certainly will be found in these first, or sentinel, nodes. This method minimizes the risk for developing some arm swelling, called “lymphedema” as a result of disrupting the lymphatic system.
Following lumpectomy, radiation is almost always required in order to minimize the possibility of recurrence. Decades ago, when mastectomy was the only surgical option, several national and international studies were done to determine if women could undergo a less radical operation. Although these studies clearly showed that women did just as well long term with lumpectomy instead of mastectomy, radiation therapy was needed to keep the local recurrence rate to a minimum. In these studies, women who had lumpectomy without radiation therapy had cancer come back in the breast about 30% of the time. And so, these days when a lumpectomy is considered the preferred surgical option, it is almost always considered as part of a “package deal”, with radiation therapy to follow.
Radiation therapy for breast cancer has traditionally been given as several daily brief treatments to the entire breast, usually taking about 4 weeks. It is given this way in order to minimize the side effects of the skin. The effect of the radiation on the breast tissue is “cumulative”, meaning that the total required dose can be divided into very small daily doses, and as long as the sum of the small doses equals the required total dose, you will achieve the desired outcome. If higher daily doses would be given instead, the skin would get radiation burns. Even with the small doses given, this can sometimes be a problem. The radiation therapy physician will discuss these possibilities with you and will monitor you for any evidence of problems during the six weeks of treatment.
Chemotherapy is a standard part of treatment for most women with Stage 2 breast cancer, although the decision for chemotherapy is based on several different factors. Your age and general health, including any other major medical problems must be considered. The characteristics specific to your cancer may indicate that chemotherapy won’t have much impact. Each woman brings her own priorities and concerns regarding chemotherapy, and these are of course considered by your doctors. There are a number of ways to try to predict your risk for recurrence, and depending on how high or low that risk is, each individual woman may make their own choice.
In some cases, your doctors may recommend a mastectomy instead of a lumpectomy. This might be because the tumor size is big compared to the size of your breast so that the cosmetic result following lumpectomy might be poor. There may be worrisome calcifications scattered through all of your breast, which can be worrisome for other tiny cancer spots. You may have more than one cancer found in different parts of your breast. If you have had cancer come back after previous lumpectomy and radiation therapy, you almost always will need a mastectomy. If you test positive for one of the BRCA mutations, you will probably be advised to have a bilateral mastectomy. And it may be that as you consider your options, mastectomy may just seem to be a better choice. But in most cases, your surgeon should at least be offering breast conservation, unless it is made very clear why it would not be appropriate.
If you do have a mastectomy, in most cases, a breast reconstruction is an option. In many cases, this can be done immediately. In other words, you have your surgery for the mastectomy, and you wake up afterward with the reconstructed breast. Not all women choose to undergo breast reconstruction or may choose to delay the reconstruction until a later date. The discussion about what is best for you can get a bit complicated and is best done with your surgeon and plastic surgeon. There are many options available these days, including the use of some tissue from other adjacent parts of your body, silastic or saline implants, or a combination of these. Surgeons may leave the skin “envelope” of your breast (a “skin-sparing mastectomy”), and then re-fill the skin with the transferred tissue or with an implant. This method seems to give better cosmetic results in general.
It is important to know that if radiation therapy is necessary, it can affect the cosmetic results of a reconstruction, so if you are going to need radiation even after a mastectomy, your doctors should discuss the possible added risks.
Your cancer tissue will be tested for any sensitivity to hormones. The two routine tests are “estrogen receptor (ER)” and “progesterone receptor (PR)”. The ER is considered the more important one, but basically, if either or both of these is “positive (+)”, then it means the cancer cells can be stimulated by estrogen. There are a number of drugs which can block the effects of estrogen on any cancer cells remaining in the body, and so one of these drugs is routinely used for ER+ cancers. But these drugs might blunt the effectiveness of chemotherapy or radiation therapy if they are given at the same time. For this reason, any hormone blocking treatment is usually held until after the other treatments (surgery, radiation therapy, chemotherapy) are completed. The estrogen-blocking drugs include tamoxifen, Arimidex (anatrozole), Femara (letrozole), and Aromasin (exemestane). Tamoxifen works differently from the other three, by blocking the receptors for estrogen on the breast cells. The other three are all in the class of drugs called “aromatase inhibitors”. These act by blocking the production of estrogen in the body. An important thing to understand about these drugs is that they do not inhibit the production of estrogen in functional ovaries. For this reason, aromatase inhibitors are not effective in women before menopause. And so, for women who have not yet gone through menopause, tamoxifen is the only tried and true option for hormone-blocking treatment in ER+ women.
Your cancer might be sent for a test called the OncotypeDX Recurrence Score (this is only appropriate in patients with cancers sensitive to estrogen (ER-positive) and HER2 negative). This test has been shown to do a better job of knowing, or predicting, whether there would be any benefit to giving chemotherapy.
The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three-week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on your cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.
One routine assay done on breast cancers is called the HER2 assay. We have learned that when this gene is “overexpressed” in cancer, it is more likely to act aggressively, by spreading to other organs. But we have also discovered some drugs, which are specifically designed to block this protein’s function and they are very effective at decreasing the aggressiveness of these cancers. Only about 15% of breast cancers have this genetic dysfunction, but if your cancer is “HER2 positive”, you likely will be advised to receive these specific chemotherapy agents, called Herceptin (trastuzumab) and Perjeta (pertuzumab), in addition to some other drugs. The Herceptin is usually given in cycles over the entire first year following the initial treatment.
You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website. Here is a direct link to their online “virtual book” for with breast cancer of any stage.
Whether surgery is done before or after chemotherapy, breast conservation is typically very desirable. The surgery for breast conservation is usually called “lumpectomy and sentinel lymph node biopsy”, or “partial mastectomy and sentinel lymph node biopsy”, and almost always requires radiation therapy afterward.
In addition to the lumpectomy or mastectomy, the lymph nodes under the arm will usually be sampled. In Stage 2, some patients will already be known to have some cancer cells in at least one or more of the lymph nodes. Historically, women with any positive lymph nodes would be advised to have removal of all the lymph nodes under the arm (called a “complete axillary dissection”), but this can now often be avoided based on more recent studies. Positive lymph nodes may be effectively treated with radiation therapy instead, which lowers the risk of arm swelling, called “lymphedema” that can occur as a result of disruption of lymphatic channels from the arm.
Radiation therapy is virtually always used after lumpectomy, to decrease the likelihood of recurrence of cancer in the breast. And in Stage 2 cancers, even after a mastectomy, radiation therapy may be recommended for treatment of the chest wall.
You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website. There is a direct link to their online “virtual book” for with Stage I or II breast cancer.
Stage 3 (Invasive) Breast Cancer
If your cancer is a Stage 3, it means that the tumor in your breast is a bit larger than most, and/or there is disease seen in the lymph nodes under the arm (in the axilla). There is no evidence of disease spread to organs beyond the breast and the lymph nodes. Using the TNM staging, the possible combinations within stage 3 are
- Stage IIIA: T0 to T2, N2, M0 / T3, N1 or N2, M0
- Stage IIIB: T4, N0 to N2, M0
- Stage IIIC: any T, N3, M0
Your doctors use their best estimate about the tumor size and the presence of cancer in lymph nodes or elsewhere to come up with the “clinical” stage, in order to make appropriate treatment plans prior to the surgery. Once the surgery has been done, these estimates are re-evaluated, based on actually looking at these tissues under the microscope. So the clinically estimated stage may change based on the “pathologic” findings.
Surgery plays an important role in Stage 3 breast cancer, but chemotherapy is equally, if not more important. With these more advanced cancers, the order of treatment more often begins with chemotherapy. This method allows us to see that in your individual case, the selected chemotherapy is effective in shrinking the tumor down in size. Not only does this let us know with certainty that your cancer is not resistant to the selected treatment, the shrinking tumor makes it easier to surgically remove it with clear margins later on. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL remaining cancer has disappeared. These patients have a particularly good prognosis.
Chemotherapy is a standard part of treatment for most women with Stage 3 breast cancer, although the decision for chemotherapy is based on several different factors. Your age and general health, including any other major medical problems must be considered. The characteristics specific to your cancer may indicate that chemotherapy won’t have much impact. Each woman brings her own priorities and concerns regarding chemotherapy, and these are of course considered by your doctors. There are a number of ways to try to predict your risk for recurrence, and depending on how high or low that risk is, each individual woman may make their own choice.
The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three-week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.
One routine assay done on breast cancers is called the HER2 assay. We have learned that when this gene is “overexpressed” in cancer, it is more likely to act aggressively, by spreading to other organs. But we have also discovered some drugs, which are specifically designed to block this protein’s function and they are very effective at decreasing the aggressiveness of these cancers. Only about 15% of breast cancers have this genetic dysfunction, but if your cancer is “HER2 positive”, you likely will be advised to receive these specific chemotherapy agents, called Herceptin (trastuzumab) and Perjeta (pertuzumab), in addition to some other drugs. The Herceptin is usually given in cycles over the entire first year following the initial treatment.
You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website. Here is a direct link to their online “virtual book” for with breast cancer.
Whether surgery is done before or after chemotherapy, breast conservation is typically very desirable. The surgery for breast conservation is usually called “lumpectomy and sentinel lymph node biopsy”, or “partial mastectomy and sentinel lymph node biopsy”, and almost always requires radiation therapy afterward. In Stage 3 breast cancer, mastectomy may be recommended instead. This may be necessary if the cancer is very large, there is more than one place in the breast where cancer is present, or if the cancer in the breast has involved the overlying skin. There are other scenarios where mastectomy may be a preferred choice, for instance, if it is the woman’s preference, if there has previously been cancer in the opposite breast, if a genetic test called BRCA is positive, or if there is some reason that radiation therapy cannot be given.
In addition to the lumpectomy or mastectomy, the lymph nodes under the arm will usually be sampled. In Stage 3, many patients will already be known to have some cancer cells in at least one or more of the lymph nodes. Historically, women with any positive lymph nodes would be advised to have removal of all the lymph nodes under the arm (called a “complete axillary dissection”), but this can now often be avoided based on more recent studies. Positive lymph nodes may be effectively treated with radiation therapy instead, which lowers the risk of arm swelling, called “lymphedema” that can occur as a result of disruption of lymphatic channels from the arm.
Radiation therapy is virtually always used after lumpectomy, to decrease the likelihood of recurrence of cancer in the breast. And in Stage 3 cancers, even after a mastectomy, radiation therapy may be recommended for treatment of the chest wall. The radiation therapy is given as small doses on a daily basis, 5 days a week for about 4 weeks. You may have heard about a radiation therapy treatment given over just one week, and this is discussed elsewhere in this website, but it is not a good option for women with Stage 3 cancer.
If you do have a mastectomy, in most cases, a breast reconstruction is an option. In many cases, this can be done immediately. In other words, you have your surgery for the mastectomy, and you wake up afterward with the reconstructed breast. Not all women choose to undergo breast reconstruction or may choose to delay the reconstruction until a later date. The discussion about what is best for you can get a bit complicated and is best done with your surgeon and plastic surgeon. There are many options available these days, including the use of some tissue from other adjacent parts of your body, silastic or saline implants, or a combination of these. Surgeons may leave the skin “envelope” of your breast (a “skin-sparing mastectomy”), and then re-fill the skin with transferred tissue or with an implant. This immediate reconstruction method seems to give better cosmetic results in general. Be aware that it often requires additional trips to the operating room to achieve the final result.
It is important to know that if radiation therapy is necessary, it can affect the cosmetic results of a reconstruction, so if you are going to need radiation even after a mastectomy, your doctors should discuss the possible added risks.
Stage 4 (Invasive) Breast Cancer
If your cancer is Stage 4, it means that there is either a strong suspicion, or a biopsy-proven spread of your cancer to other organs, such as the liver, lungs, bone, or brain. No matter what organ cancer has spread to, the Stage is the same, Stage 4. Although we would love to have a treatment that could routinely cure this group of cancers, there is no known cure for Stage 4 cancer, no matter where the spread is seen.
In these cases, priority is given to treating cancer in the organs where it has spread. Sometimes, even though there is still cancer in the breast, your doctors may not necessarily recommend removal of cancer in the breast. If there is going to be cancer remaining in other parts of the body, then removing just cancer in the breast will not have any definite impact on your overall survival. Removal of cancer in the breast may be recommended if it would make it easier to manage, for instance, if it seems to be getting larger despite treatment, or if it is going to break through the skin. Treatment in such cases tends to be very individualized, so it is not easy to give a summary of what should be recommended.
Although there is no known cure for stage 4 breast cancer, the disease can often be controlled so that it either does not grow or only grows slowly, with appropriate treatment. There are a number of clinical trials available for treating Stage 4 breast cancer, and we at DeKalb Surgical strongly recommend considering any trials that may be available to you. The oncologists we work with can discuss these options further with you. Dr. Kennedy has served on the board of GA CORE, a network of cancer specialists across Georgia, who are committed to making clinical trials available to all Georgia citizens.
Treatment of Stage 4 breast cancer includes primarily chemotherapy, hormone-blocking therapy (only for hormone-sensitive cancers, determined by testing for estrogen receptors (ER) and radiation therapy for disease spread to the brain, or to the bones. Surgery is not commonly used for this group.
The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three-week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.
Once each of these factors is determined, the three numbers are combined into a stage. Basically, the higher the numbers, the higher the stage. The American Cancer Society has an entire summary assessing the stages.
| Tumor Size (Invasive Component) | T |
|---|---|
| DCIS, Non-Invasive (Cancer “Seeds”) | 0 |
| 0-2 cm | 1 |
| >2-5 cm | 2 |
| >5 cm | 3 |
| Ulcerating the Overlying Skin, or Growing into the Chest Muscles | 4 |
As we learn more about breast cancer, we may find even better ways to categorize them. We already have a few extremely important tests by which we further categorize each cancer, based on the presence or absence of certain proteins or genes in the cancer cells. These tests include estrogen and progesterone receptors (ER and PR), and HER2. These tests are very important because if the tests are positive, then we know there is a high chance of benefit from very specific treatment, and if the tests are negative, we know that using these targeted treatments would be of no benefit at all. As other similar tests become available, it may be that we will rely less on the TNM staging and rely more and more on specific genetic characteristics which give high predictability of response to matching targeted treatments.
FAQs
Is there anything I can do to prevent getting breast cancer?
We do know something about risk factors for breast cancer. Breast cancer incidence is higher in patients who are overweight, those who drink moderate to high amounts of alcohol daily, and those who consume a diet high in saturated fats. There is also a higher incidence in those who have early onset of menstruation, those who have no full-term pregnancies until late in life, or those who never have any pregnancies. Also, for those with children, breast feeding appears to decrease the incidence of breast cancer.
Most women will not want to base their family planning on decreasing their cancer risk, but it’s at least helpful to understand these potential implications. But some basic preventive life styles make sense for most everyone, namely, avoiding saturated fats as much as possible, abstaining from alcohol, and maintaining an ideal body weight. Other good life style measures in general include complete abstinence form tobacco products, a diet high in fiber, and a regular exercise program.
I don’t know what stage my cancer is.
If you have had a biopsy and already know that it’s cancer, but don’t know the stage, you can ask your doctor. Most cancers when diagnosed are in the Stage 0, 1, or 2 categories. Each stage has certain specific treatment options appropriate for that category of cancers, as you will see in the paragraphs above.
If your doctor seems unable to tell you what stage your cancer is, you may want to consider seeing us for a second opinion. Making an assessment of the stage of your cancer is critical in deciding on appropriate treatment. If you want to schedule an appointment, please contact us.
For some information on survival rates for breast cancer, you can see our outcome results.
I had a breast biopsy that showed invasive cancer. What should be done now?
“I Had a Breast Biopsy That Showed Invasive Cancer. What Should Be Done Now?”
You will need to be evaluated to decide on an individualized treatment plan, based on the specific details of your case. Several factors must be considered, including the type of breast cancer (ductal is the most common subtype, and lobular is the other, but there are even subtypes of the subtypes), your age and menopausal status, the apparent size of the tumor, your medical history, and any pertinent abnormalities noted on a thorough physical exam, findings on mammogram and possibly additional imaging studies, and some molecular characteristics of the cancer (you might think of these as the “fingerprint” of the cancer), primarily the estrogen receptor (ER) and HER2 status. For some women, an additional assay called the OncotypeDX Recurrence Score may be ordered as well.
All these elements should be considered by your surgeon. In cases where the cancer appears small, and there is no evidence of cancer spread to lymph nodes or elsewhere, the next treatment step is surgery. This will usually mean a “lumpectomy and sentinel lymph node biopsy”. A “lumpectomy”, which can also be referred to as a “partial mastectomy”, removes enough tissue around the cancer so that no cancer cells are seen along the margins of the removed tissue. I like to use the analogy of a hard-boiled egg. The yellow yolk (which represents the cancer) on the inside should have “egg white”, or normal breast tissue, on all sides, such that that yellow egg yolk is not seen anywhere on the outside surfaces of the egg. Now in actuality, cancer cells aren’t yellow like an egg yolk, and one cannot always tell during the surgery that the margins are clear. But fortunately in over 90% of the cases at DeKalb Surgical, the margins are clear with just one procedure. At many centers, as many as 40-50% of women need a second procedure to get “clear margins”.
The “sentinel node biopsy” part of the operation involves a second small incision under your arm (called the axilla), combined with an injection of dye in your breast, usually at the nipple. The idea is to check to see if there is any cancer spread to the lymph nodes. The dye injection allows the surgeon to identify the first nodes to receive any lymph flow from the breast; if any cancer cells have spread to the lymph nodes, they almost certainly will be found in these first, or sentinel, nodes. This method allows the surgeon to leave all of the other lymph nodes alone, unless cancer cells are seen in the sentinel nodes.
Following lumpectomy, radiation is almost always required in order to minimize the possibility of recurrence. Decades ago, when mastectomy was the only surgical option, several national and international studies were done to determine if women could undergo a less radical operation. Although these studies clearly showed that women did just as well long term with lumpectomy instead of mastectomy, radiation therapy was needed to keep the local recurrence rate to a minimum. In these studies, women who had lumpectomy without radiation therapy had cancer come back in the breast about 30% of the time. And so, these days when lumpectomy is considered the preferred surgical option, it is almost always considered as part of a “package deal”, with radiation therapy to follow.
Radiation therapy for breast cancer has traditionally been given as several daily brief treatments to the entire breast, usually taking about 6 weeks. It is given this way in order to minimize the side effects to the skin. The effect of the radiation on the breast tissue is “cumulative”, meaning that the total required dose can be divided into very small daily doses, and as long as the sum of the small doses equals the required total dose, you will achieve the desired outcome. If higher daily doses would be given instead, the skin would get radiation burns. Even with the small doses given, this can sometimes be a problem. The radiation therapy physician will discuss these possibilities with you, and will monitor you for any evidence of problems during the six weeks of treatment.
There is a new way to give the radiation therapy after lumpectomy, which is an option for some women, called partial breast irradiation therapy. This method can be completed within just 5 days, with two daily treatments each day. The radiation is given by placing a tiny “radioactive seed” inside the breast briefly for each treatment. This method almost completely eliminates the risk of skin damage, and this is why the treatment can be completed so much faster. This technique has been used at DeKalb Surgical since 2006 for selected women, so we have lots of experience with it.
For cancers that are larger, and for cancers that have already spread to lymph nodes or elsewhere in the body, surgery sometimes is delayed until after completion of some chemotherapy. This portion of the treatment (called neoadjuvant therapy) is managed by an medical oncologist, and not the surgeon. Modern treatment of breast cancer involves a team of specialists to customize your care, based on the unique characteristics of each individual case. This team includes the surgeon, the oncologist, radiation therapist, and often others, such as the plastic surgeon, physical therapist, geneticist, nutritionist, clinical trials specialists, as well as others, depending on your specific needs.
In some cases, it may be best to undergo chemotherapy first, to shrink down the tumor, and then follow with the surgery to remove any remaining cancer cells. An advantage of this sequence is that we can see that in your specific case, the selected chemotherapy is effective, since we will be able to see that the cancer, if it’s palpable, actually shrinks during treatment. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL the remaining cancer has disappeared. These patients have a particularly good prognosis.
At DeKalb Surgical, we have available many clinical trials for patients with breast cancer. Clinical trials allow us to offer tomorrow’s breast cancer treatments today. These trials often include newly approved drugs, which have shown benefit in more advanced breast cancers, and now are being tested in women with breast cancers that are more contained (ie, a lower stage). Or they may be testing a less radical method of giving the usual radiation therapy to the breast after surgery. Other trials are intended to show that hormonal treatment (which is much easier to tolerate compared to chemotherapy) is effective in shrinking tumors before surgery. Not all women are candidates for clinical trials, but studies have shown that women who participate in clinical trials tend to have better outcomes than those who don’t go on a trial.
I had a breast biopsy that showed ductal carcinoma in situ (DCIS). What should be done now?
Although no one ever wants to be told that they have cancer, the finding of ductal carcinoma in situ (DCIS) is one of those situations where we truly have found a cancer at a stage where it can be nipped in the bud. (In fact, some would even argue that it is not really a cancer “yet”, if it has not actually invaded into the surrounding tissue.) The “in situ” phrase means that we can tell for sure that these cells have the POTENTIAL to do their cancer thing (which means, to invade into surrounding tissue and eventually spread elsewhere), but that they have not yet invaded even the tissue right around the DCIS cells. You can think of these cells as “cancer seeds”, which haven’t yet sprouted, but have all the capability of doing so if left in place.
When DCIS is seen on a biopsy, you will usually need to have more tissue removed from your breast (usually the additional tissue removed is about the size of an ice cream scoop). This is almost always done as on open surgical excision in the operating room, either with sedation or general anesthesia, though sometimes under local anesthesia. This surgical excision is the most important treatment, and it is necessary to remove enough tissue so that none of the DCIS is seen along any of the margins of the removed tissue.
This is not always as simple as it might seem, because the DCIS can only be seen under the microscope, and the tissue is not usually examined under the microscope until after preserving the removed tissue in formalin overnight. This method gives more reliable information than trying to examine the tissue immediately (called a frozen section). This means that there are some women in whom the margins will show some more DCIS, and this will require another trip to the operating room to remove more tissue. This return to the operating room is necessary more often than you might think, as often as 50% of the time at some centers, whether here in Atlanta, or at an academic center. At DeKalb Surgical, this is only necessary about 10% of the time. I wish it would never happen, but sometimes even the non-invasive cancer cells can extend along the breast ducts in various directions. Obtaining clear margins is a matter of experience, compulsion with orientation of the tissue for the pathologist, and to some extent, how much additional breast tissue is removed.
In some cases, when the surgical excision is done, there may be some actual invasion seen in an adjacent area, that was not seen on the initial biopsy. In such cases, the situation changes a bit. In most cases of invasive cancer, even if only a tiny area, it is usually recommended to also surgically check some of the lymph nodes under your arm, to be sure there are no cancer cells seen there.
Although surgical excision for clear margins is the most important treatment for DCIS, radiation therapy AND 5 years of anti-hormonal therapy (with tamoxifen) is fairly standard additional treatment, with the intention of minimizing the possibility that you might ever develop another cancer in your breast. There is no need for chemotherapy in these very early stage cases. Your surgeon should discuss these issues with you in more detail. Probably the most important thing to remember if you have DCIS is that essentially all women are cured of their cancer when it is found at this stage.
You may wonder why radiation therapy and hormone-blocking treatment are recommended if all the DCIS is surgically removed. That’s a good question, and the answer comes from what we have learned over the past several decades of treating such patients. Studies have compared treatment with lumpectomy only versus lumpectomy plus giving radiation therapy, and also with or without giving hormone blocking treatment (tamoxifen). These studies showed that a higher percentage of patients who only had lumpectomy had cancer come back again over the following 5-10 years. And when the cancer comes back, sometimes it is invasive instead of non-invasive. After lumpectomy only, the recurrence rate is about 35%. If radiation therapy and tamoxifen are added, the recurrence risk is under 5%.
I like to think of the radiation therapy in this case as analogous to the weed preventive that you might apply to your yard in the spring. You might have had one sprig of crabgrass that you pulled out completely. You don’t see any other crabgrass in your yard, but you figure that it could pop up at a later date. The weed preventive will do just that—help prevent you from having more crabgrass in the future. In the same way, just removing the seeds of breast cancer (DCIS) might not be enough to keep some seeds sprouting and taking root elsewhere in your breast in the future. Radiation therapy decreases that risk considerably I most cases.
It is important to understand that the treatment of breast cancer, and DCIS, is evolving. Currently there is interest in trying to identify subsets of women for whom we feel the risk of invasive disease in the future is so low that we could avoid the usual radiation therapy and anti-hormonal therapy. Such treatment decisions can be individualized, and in your particular case, your priorities should certainly be considered in deciding on what treatment you ultimately received. Your priorities are given the uppermost consideration at DeKalb Surgical in formulating an individualized treatment plan.
How can I determine how high my risk of breast cancer is?
We can give an estimate of a woman’s risk of developing breast cancer based on several factors such as family history, prior breast biopsy results, age at onset of menstrual periods, etc. One popular “model” for quantifying this risk is called the Gail model. By “plugging in” all the pertinent information, a calculation of the 5-year and lifetime risk can be made. For the “no risk” women, her 5 year risk would be about 1%, meaning that if there were 1000 women with no risk factors, in five years, approximately 10 of them would have developed breast cancer. A woman who has one or more risk factors, such as family history, no pregnancies, etc, her 5 year risk may be 1.5%, or 2.5% or higher. This would mean that in a group of 1000 women with all those same risk factors, 15 or 20 would develop cancer over the next five years.
You may want to look at a similar risk calculation tool at the National Cancer Institute website, where you can do your own calculation.
Lifetime risk for a woman with no risk factors would be in the range of 10%, meaning that 100 of 1000 similar women would develop breast cancer sometime during their lifetime. For women with one or more risk factors, their lifetime risk may be 15% or perhaps as high as 50%.
If my risk of developing breast cancer is high as calculated by the Gail model or other risk assessment tool, is there anything I can do about it?
In 1998, a landmark study was published regarding the use of tamoxifen in the prevention of breast cancer. About 13,000 women were enrolled in this five year trial, comparing tamoxifen to a placebo (sugar pill). The incidence of breast cancer development over about five years was decreased by about 50%. In the placebo group, about 20 out of 1000 women developed cancer, whereas only about 10 out of 1000 women developed cancer in the tamoxifen group. These results are dramatic, in that this the first ever drug study to demonstrate the ability to prevent breast cancer from developing in the first place.
If a women chooses to take tamoxifen for prevention, it must be taken for a total of five years. One must be aware that there are some potential undesirable side effects. There were a few more cases of endometrial cancer when taking tamoxifen, and there were more women with blood clot problems and there may be side effects of hot flashes, vaginal discharge, cataract formation, and depression. But for some women the benefits may clearly outweigh the risks.
I have heard that Evista (raloxifene) can also decrease my risk of getting breast cancer. Is this true?
Raloxifene is a drug that was initially approved for the prevention of osteoporosis. In the study which was conducted to look at its effect in osteoporosis, it was noted incidentally that there were fewer women diagnosed with breast cancer when taking raloxifene.
On the basis of these findings, a large trial was conducted a few years ago, including almost 20,000 women, which compared the use of Evista (raloxifene) to tamoxifen for the prevention of breast cancer in women who were at higher than average risk for developing breast cancer. This was called the STAR trial (Study of Tamoxifen and Raloxifene). The results were published in 2006, and showed that Evista also decreased the incidence of breast cancer over a 5 year period. It is important to understand the size of the benefit. These women had an average estimated risk of about 4% for developing breast cancer over the next 5 years. This means that out of 100 women in the trial, only 4 would be expected to be diagnosed with cancer in 5 years. But in the general population only 1 or 2 out of 100 will develop cancer in 5 years, so the risk is double or more. Now in the study, with 5 years of either tamoxifen or Evista (raloxifene), only about 2 out of 100 women were diagnosed with breast cancer over 5 years, so the drugs both decreased the incidence of cancer by half. While this is really good, the benefit is limited to only 1 or 2 women out of 100 who take it, at least over the first 5 years. It seems that the higher one’s risk is, the more attractive these drugs become as preventive treatment. You can find more information at the National Cancer Institute website about this trial. Another informative NCI site.
Have more general questions about breast issues? Check out general breast problem FAQs.