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.
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:
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.
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.1
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 |
Lymph Node Status (in the Axilla, or Armpit) | N |
---|---|
No Lymph Nodes With Cancer | 0 |
1-3 Lymph Nodes With Cancer | 1 |
4-9 Lymph Nodes With Cancer | 2 |
10 or More Nodes and Some Other Advanced Findings | 3 |
Is Metastatic Disease Present? | M |
---|---|
No | 0 |
Yes (Typically Might be in Liver, Lungs, Bone, or Brain) | 1 |
If you could not use your anus for a few weeks, the fissure would probably heal faster, but, of course, you have to eat… and eliminate. Fortunately, over half of fissures heal either by themselves or with non-surgical treatment in a few weeks or months. Superficial fissures rarely require surgery; most are able to be treated with topical medications. Non-surgical treatments may include:
Call your doctor if you have any severe bleeding or fever, or if the fissure becomes more painful or shows no improvement after 3 days of treatment.
Two new forms of treatment have recently been reported. One is the use of Nitroglycerine cream to the anal area to relax the anal muscle spasm. Though frequently effective, many patients experience headaches when using this ointment. The other new treatment is the use of Botox (botulism toxin) injections to weaken the anal sphincter and allow the fissure to heal. Experience with this novel technique is limited.
If a fissure continues to cause pain and bleeding and does not respond to conservative medical therapy, it is considered chronic and surgery may be required. Chronic fissures heal only 10% of the time without surgery. This may involve an operation that divides one of the circular anal muscles (internal lateral sphincterotomy). Surgery can usually be performed without an overnight hospital stay. The pain often disappears a few days after surgery, though full healing requires one to two months Most patients are back to normal activity within a week or two.
There is a risk of fecal incontinence (loss of the ability to control bowel movements) with this procedure, but the incidence of this is quite low. Infection and complications incident to anesthesia are also possible, but again the risks are low. If you have any questions about this, you should discuss them with your doctor.
More than 90% of patients who require surgery for this problem have no further trouble from fissures as long as they take measures to prevent constipation and straining with bowel movements.