Staging
Breast Cancer
Breast Cancer risk factor | genetic | malignant | stats | staging | metastic | unusual cancer

 

Staging

 

Patients often ask what stage their cancer has been diagnosed at. The staging philosophy is a tricky one as the management options for breast cancer (particularly regarding new chemotherapy agents and different uses for existing ones) is such a dynamic subject that patients having later stage cancers sometimes live longer than some patients with earlier stage cancers.

 

Staging is made on clinical findings but this is often not accurate. Accurate staging can only be made after surgery, where the specimens are sent to the pathologist for histologic examination. Now the staging can be made with precision. This clinical staging (what we find on examination) is confirmed by pathology studies of the tumour and the axillary nodes. Here the pathologist studies the tumour and axillary nodes under a microscope (histopathology) to give a definitive diagnosis. The pathology may modify the staging. For example, axillary nodes may be palpable on the side of the lump in the breast on clinical examination (called ipsilateral nodes). Yet, when the pathologist examines these nodes that have been removed by the surgeon, it may show no malignant involvement (no metastatic spread), but just reactive immune stimulation (sinus histiocytosis)which causes nodal enlargement, but not from the cancer. Thus although the patient is a clinical stage II breast cancer, it is pathologically a stage I cancer, because the nodes, although enlarged and palpable, are not involved with lymphatic metastases.

 

Staging systems are used to classify breast cancer, so that the doctor can treat the disease with a logical basis. The most commonly used staging system is the TNM staging system.

 

Staging breast cancer allows doctors to logically treat and prognosticate (predict the outcome) for the patient. It allows doctors at particular centres to compare their results with other centres all over the world. Thus treatment regimens in South Africa can be compared with those in the United Kingdom and United States of America.

 

We are often asked by patients what stage their cancer is. The question they should rather be asking is what features my cancer has that may increase the chance of it coming back.

 

Part of the staging is to perform certain tests to determine whether the cancer has spread:

Metastases are little islands of tumour cells that have spread from the primary cancer and taken root in distant tissues and organs. It is these metastases that eventually cause death. Doctors detect metastases with various methods.

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X-ray chest for lung spread.

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X-ray bones for bony spread.

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Brain scan for cerebral metastases (MRI).

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Ultrasound (sonar and CAT scan for liver secondaries.

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Blood tumour markers (these should be used as a serial assessment, not as individual values).

Note that a cancer has to be at least 5mm in size or be symptomatic for these tests to positive for cancer.

New Developments in Breast Cancer Staging
Over the next five years the staging of breast cancer may change to encompass a bone marrow aspirate, sentinel node biopsy of a gland and tumour biology.

Already tumour biology (i.e. certain features about the tumour) determines whether a woman will have chemotherapy or not. It is possible that the biology (personality) of the tumour will be more important than the size, particularly in small cancers that have not spread to the glands and will help determine who will get chemotherapy and who will not.

The principles of staging a patient are to guide doctors about treatment options and to aid research so all cancer clinicians are able to speak the same language. The most commonly used staging system is the TNM staging system, with T referring to tumour size, N referring to nodal status and M being used to donate metastatic disease (cancer that has spread beyond the breast and regional lymph nodes).

 

Principles of the TNM staging system
In brief: There are 4 Ts, 3Ns and different Ms

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T1 = tumour size less than 2cm

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T2= tumour size between 2cm and 5cm

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T3= tumour size greater than 5cm

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T4 =tumour that have attached to the structures (skin or chest wall, hot red breast of inflammatory cancer)

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N1 refers to palpable mobile lymph nodes

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N2 refers to fixed lymph nodes

 

There are four stages: stage 1 and 2 cancers are early; stage 3 cancers are locally advanced (large breast cancers greater than 5cm) and stage 4 cancers have spread to elsewhere (M+).

Patients would be wise to use aids as adjuvant online and to find out about discussions on new and recent developments in breast cancer treatment.

It is your right to ask about new treatments and your time with your doctor is just that: YOUR TIME so take as much time as you need during a consultation. It is your body and your life so become involved with your health.