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What is Breast Cancer?
About the breast
The breast is mostly made up of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes, carrying the milk from the lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple). Blood and lymph vessels also run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes, the tiny, bean-shaped organs that help fight infection.
About breast cancer
Cancer begins when normal cells in the breast change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).
Breast cancer spreads when the cancer grows into other parts of the body or when breast cancer cells move to other parts of the body through the blood vessels and/or lymph vessels. This is called metastasis. Breast cancer most commonly spreads to the regional lymph nodes. The lymph nodes can be axillary (located under the arm), cervical (located in the neck), internal mammary (located under the chest bone), or supraclavicular (located just above the collarbone). When it spreads further through the body, it most commonly spreads to the bones, lungs, and liver. Less commonly, breast cancer may spread to the brain. The cancer can also recur (come back after treatment) locally in the skin, in the same breast (if it was not removed as part of treatment), other tissues of the chest, or elsewhere in the body.
Types of breast cancer
Most breast cancers start in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancer that begins in the lobules is called lobular carcinoma. The difference between ductal and lobular cancer is determined by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease), who examines a tumor sample removed during a biopsy.
If the disease has spread outside of the duct or lobule and into the surrounding tissue, it is called invasive or infiltrating ductal or lobular carcinoma. Cancer that is located only in the duct or lobule is called in situ, meaning “in place.” How in situ disease grows and spreads, as well as how it is treated, depends on whether it is ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).
Most in situ breast cancers are DCIS. Currently, oncologists recommend surgery to remove DCIS to help prevent the cancer from becoming an invasive breast cancer and spreading to other parts of the breast or the body. Radiation therapy and hormonal therapy may also be recommended for DCIS.
LCIS is not considered cancer and is usually monitored by the doctor. LCIS in one breast is a risk factor for developing invasive breast cancer in both breasts .
Other, less common types of breast cancer include medullary, mucinous, tubular, metaplastic, and papillary breast cancer, as well as other even less common types. Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers. It may be misdiagnosed as a breast infection because there is often swelling of the breast and redness of the breast skin that starts suddenly. Paget’s disease is a type of cancer that begins in the ducts of the nipple. The skin often appears scaly and may be itchy. Although it is usually in situ, it can also be an invasive cancer.
Symptoms & Signs
Women with breast cancer may experience breast changes or symptoms, but many women do not show any of these signs or symptoms when diagnosed. Many times, breast signs or symptoms can be caused by a medical condition that is not cancer. If you are concerned about a sign or symptom, please talk with your doctor.
The signs and symptoms that should be discussed with a doctor include:
Lumps that feel like a hard knot (many women normally have lumpy breasts) or a thickening in the breast or under the arm
Change in the size or shape of the breast
Nipple tenderness, discharge (may occur suddenly, be bloody, or occur in only one breast), or physical changes (such as a nipple turned inward or a persistent sore)
Skin irritation or changes, such as puckers, dimples, scaliness, or new creases
Warm, red, swollen breasts with or without a rash resembling the skin of an orange (called peau d'orange)
Pain in the breast (usually not a symptom of breast cancer, but it should be reported to a doctor), particularly breast pain that doesn’t go away
Your doctor will ask you questions about the symptoms you are experiencing to help find out the possible cause of the problem, which can help the doctor know what tests are needed to make a diagnosis. Questions may include how long you’ve been experiencing the symptom(s) and how often.
If cancer is diagnosed, relieving any symptoms of the cancer and side effects from cancer treatment is an important part of cancer care and treatment. This may also be called symptom management, supportive care, or palliative care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.
A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.
Most women who develop breast cancer have no obvious risk factors and no family history of breast cancer. This means that all women need to be aware of changes in their breasts and talk with their doctors about receiving regular clinical breast examinations (an examination of the breast by a doctor) and mammograms (x-ray of the breast that can detect a tumor that is too small to be felt). It is likely that more than one risk factor influences the development of breast cancer.
The following factors may raise a woman’s risk of developing breast cancer:
Age. The risk of developing breast cancer increases as a woman ages, with most cancers developing in women older than 50.
Personal history of breast cancer. A woman who has had breast cancer in one breast has a 1% to 2% chance per year of developing a second breast cancer in her opposite breast, if she has no other risk factors.
Family history of breast cancer. Women who have a first-degree relative (mother, sister, daughter) diagnosed with breast cancer have an increased risk of the disease. Having more than one first-degree relative with breast cancer further increases that risk, especially if the cancer was diagnosed at a younger age or in a man, because it may be a sign of genetic changes that are inherited (see below). Women who have a second-degree relative (aunt, niece, grandmother, granddaughter) diagnosed with breast cancer also have a higher risk of breast cancer. The father’s (paternal) side of the family should also be considered and has the same effect as the mother’s (maternal) side when evaluating family history. For example, you may be at higher risk if your father’s sister or mother had breast cancer.
Genetic predisposition. Mutations (changes) to the breast cancer genes 1 or 2 (BRCA1 or BRCA2) are linked to an increased breast and ovarian cancer risk. Blood tests (genetic testing) are available to test for known mutations in these genes, but are not recommended for everyone and are recommended only after a person has received appropriate genetic counseling. Men may also carry these gene mutations. Breast or ovarian cancer on the paternal side of the family greatly increases the risk of having hereditary breast and ovarian cancer. Researchers estimate that about 5% to 10% of all breast cancers in the United States are linked to inherited genetic mutations, such as the BRCA1, BRCA2, and other genes. If a woman learns she has one of these genetic mutations, there are steps she can take to lower her risk of breast and ovarian cancers, and she may need a different breast cancer screening schedule than the general population, such as having tests more often or starting screening at a younger age. BRCA1 and BRCA2 genetic mutations cancer also increase a man’s risk of breast cancer, as well as the risk for other cancers.
Personal history of ovarian cancer. A history of ovarian cancer can increase a woman’s risk of breast cancer, if the ovarian cancer was because of an inherited mutation. Breast cancer gene mutations, such as BRCA1 orBRCA2, greatly increase the risk of both ovarian and breast cancers.
Estrogen and progesterone exposure. Estrogen and progesterone are hormones in women that control the development of secondary sex characteristics (such as breast development) and pregnancy. A woman’s production of estrogen and progesterone decreases with age, with a steep decrease around menopause. Long-term exposure to these hormones increases breast cancer risk.
Women who began menstruating before ages 11 or 12 or went through menopause after age 55 have a somewhat higher risk of breast cancer because their breast cells have been exposed to estrogen and progesterone for a longer time.
Women who had their first pregnancy after age 35 or who have never had a full-term pregnancy have a higher risk of breast cancer. Pregnancy may protect against breast cancer because it pushes breast cells into their final phase of maturation. Breastfeeding may also help lower the risk of developing breast cancer before menopause.
Postmenopausal hormone replacement therapy. Recent use (within the past five years) and long-term use (several years or more) of postmenopausal (after menopause) hormone therapy with both estrogen and progesterone increases a woman’s risk of breast cancer. In fact, the number of new breast cancers diagnosed has been dropping as fewer women have been taking postmenopausal hormone therapy. However, women who have taken estrogen alone (those who have had their uterus removed for other reasons) for up to five years appear to have a slightly lower risk of breast cancer.
Oral contraceptives (birth control pills). Some studies suggest that oral contraceptives slightly increase the risk of breast cancer, while others have shown no link between the use of oral contraceptives to prevent pregnancy and development of breast cancer. Research on this topic is ongoing.
Race and ethnicity. Breast cancer is the most common cancer diagnosis in women, other than skin cancer, regardless of race. White women are more likely to develop breast cancer overall, although the disease is diagnosed more often in young black women than in young white women. Although white women are more likely to develop breast cancer, black women are more likely to die from the disease. Reasons for survival differences are unclear and probably involve both biologic and socioeconomic factors. Women of Ashkenazi Jewish heritage also have an increased risk of breast cancer because they are also more likely to have BRCAgene mutations. Breast cancer is least commonly diagnosed in Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Both black and Hispanic women are more likely to be diagnosed with larger tumors and later-stage cancer than white women. Breast cancer diagnoses have been increasing in second generation Asian/Pacific islander and Hispanic women for unclear reasons, but likely related to changes in diet and lifestyle.
Atypical hyperplasia of the breast. This diagnosis increases the risk of developing breast cancer in the future and is characterized by abnormal, but not cancerous, cells found in a biopsy of the breast.
LCIS. As explained in the Overview section, this diagnosis refers to abnormal cells found in the lobules or glands of the breast. LCIS in one breast increases the risk of developing invasive breast cancer (cancer that spreads into surrounding tissues) in either breast in the future. If LCIS is found during a biopsy, it may be removed to check for other changes, and additional treatment may be recommended. Talk with your doctor about the best way to monitor this condition.
Lifestyle factors. As with other types of cancer, studies continue to show that various lifestyle factors may contribute to the development of breast cancer.
Weight. Recent studies have shown that postmenopausal women who are overweight or obese have an increased risk of breast cancer, and they have a higher risk of having the cancer come back after treatment.
Physical activity. Increased physical activity is associated with a decreased risk of developing breast cancer and a lower risk of having the cancer come back after treatment. Regular physical activity may protect against breast cancer by helping women maintain a healthy body weight, lowering hormone levels, or causing changes in a women’s metabolism or immune factors.
Alcohol. Current research suggests that having more than one to two alcoholic drinks (including beer, wine, and spirits) per day raises the risk of breast cancer, as well as the risk of having the cancer come back after treatment.
Food. There is no reliable research that confirms that eating or avoiding specific foods reduces the risk of developing breast cancer or having the cancer come back after treatment. However, eating more fruits and vegetables and fewer animal fats is linked with many health benefits.
Radiation. High doses of ionizing radiation (such as from tanning booths and x-rays) may increase a woman’s risk of breast cancer. Radiation to the chest given at a young age, such as that given for treatment for a childhood cancer, also increases the risk of breast cancer. However, the very small amount of radiation a woman receives during a yearly mammogram has not been linked to an increased risk of breast cancer.
Breast density. Dense breast tissue may make it more difficult to find tumors on standard imaging tests, such as a mammography . Breast density may be from higher levels of estrogen, rather than a separate risk factor, and usually decreases with age. Researchers are looking at whether lowering breast density might also decrease the risk of breast cancer.
Understanding your risk of breast cancer
Several breast cancer risk assessment tools have been developed to help a woman estimate her chance of developing breast cancer. After you enter some personal and family information, including race/ethnicity, the tool provides you with a five-year and lifetime estimate of the risk of developing invasive breast cancer. Because it only asks for information about breast cancer in first-degree family members (mother, sister) and doesn’t include their age at diagnosis, the tool works best at estimating risk in women without a strong inherited breast cancer risk. For some women, other ways of determining the risk of breast cancer may work better. It’s important to talk with your doctor about how to find out your personal risk of breast cancer.
Lowering your risk of breast cancer
No intervention is 100% guaranteed to prevent breast cancer. However, depending on a woman’s specific risk factors, there are options to lower the risk of developing breast cancer.
For women with BRCA1 or BRCA2 mutations, a prophylactic mastectomy (preventive removal of the breasts) may be considered. This appears to reduce the risk of developing breast cancer by at least 95%. Women with mutations may also consider prophylactic salpingo-oophorectomy (preventive removal of the ovaries and fallopian tubes), which can reduce the risk of developing ovarian cancer, as well as breast cancer by stopping the ovaries from making estrogen.
Women who have a higher than normal risk of developing breast cancer may consider chemoprevention (the use of drugs to reduce breast cancer risk). Two drugs, tamoxifen (Nolvadex, Soltamox) and raloxifene (Evista), are approved to lower breast cancer risk. These drugs are called selective estrogen receptor modulators (SERMs). A SERM is a medication that blocks estrogen receptors in some tissues and not others. Postmenopausal women and premenopausal women may take tamoxifen, whereas raloxifene is only approved for postmenopausal women. Each drug also has different side effects. Talk with your doctor about whether you may benefit from chemoprevention for breast cancer. Other drugs are being researched to help prevent breast cancer, including aromatase inhibitors and statins.
Other ways to lower your risk of breast cancer include getting regular physical activity, staying at a healthy weight, and limiting the amount of alcohol you drink.
Mammography is the best tool doctors have to screen healthy women for breast cancer, as it has been shown to lower deaths from breast cancer. Like any medical test, mammography involves risks, such as additional testing and anxiety if the test falsely shows a possible tumor; this is called a false-positive. Occasionally (up to 10% to 15% of the time), mammography may miss a cancer, called a false-negative result. Digital mammography may be better able to find cancers, particularly in women with dense breasts.
Different organizations have looked at the evidence, risks, and benefits of mammography and have developed slightly different screening schedules:
The U.S. Preventive Services Task Force (USPSTF) recommends that women ages 50 to 74 have mammography every two years. They recommend that mammography be considered in women ages 40 to 49 after evaluating the risks and benefits of this test with a doctor.
The American Cancer Society (ACS) recommends yearly mammography beginning at age 40.
All women should talk with their doctors about mammography and decide on an appropriate screening schedule. For women with a higher risk of breast cancer, screening may be recommended at an earlier age or more often than the schedules listed above.
The USPSTF and ACS also differ on their recommendations for clinical breast examinations. The USPSTF recommends a clinical breast examination along with mammography. The ACS recommends a clinical breast examination every one to three years until age 40, then annually.
Finally, although breast self-examination has not been shown to lower deaths from breast cancer, it is important for women to become familiar with their breasts so that they can be aware of any changes and report these to their doctor. Sometimes a cancer that is growing more quickly can be found by breast examinations between regular mammograms.
Other ways to examine the breasts, such as ultrasound and magnetic resonance imaging (MRI), are not regularly used to screen for breast cancer. However, they may be helpful for women with a higher risk of breast cancer or when an abnormal change is found during an examination. According to the ACS, women at high risk for breast cancer (for example, women with BRCA gene mutations, a strong family history of breast cancer, or precancerous changes on a biopsy) should receive MRI screening and mammography, although not necessarily at the same time. MRI may be better than mammography and ultrasound at finding a small mass in a woman’s breast, especially for women with very dense breast tissue. However, an MRI has a higher rate of false-positive test results, which may mean more biopsies, surgeries, and other tests. In addition, an MRI does not show calcifications (tiny spots of calcium usually found on an x-ray), a sign of in situ breast cancer (DCIS).
Ultrasound or MRI may also be used for women with a suspicious breast change in a physical examination or mammography. If there are suspicious changes during a physical examination, further testing is needed, even if the mammogram is seen as normal. Women are encouraged to talk with their doctor about the method of screening recommended for them and how often screening is needed.
Doctors use many tests to diagnose cancer and find out if it has spread to other parts of the body beyond the breast. Some tests may also help the doctor decide which treatments may be the most effective. For most types of cancer, a biopsy (the removal of a small amount of tissue for examination under a microscope) is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
Type of cancer suspected
Severity of symptoms
Previous test results
The diagnosis of breast cancer usually begins when a woman or her doctor discover a mass or abnormal calcification on a screening mammogram, or an abnormality in the woman’s breast by clinical or self-examination. Several tests are usually performed to confirm a diagnosis of breast cancer.
The following tests may be used to diagnose breast cancer or for follow-up testing after the cancer has been diagnosed. Not every person will have all of these tests, and some imaging tests are not recommended if there are no signs that the cancer has spread.
Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more views (pictures) of the breast are taken, and it is often used when a woman is experiencing signs, such as nipple discharge or a new lump. Diagnostic mammography may also be used if something suspicious is found on a screening mammogram.
Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound can distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is usually not cancer. Ultrasounds are not used for screening.
MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium (a special dye) is injected into a patient’s vein to create a clearer picture of the breast. A breast MRI may be used once a woman has been diagnosed with cancer to check the other breast for cancer or to find out how much the disease has grown throughout the breast. It may also be used for screening, particularly along with mammography for some women with a high risk of breast cancer.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist. There are different types of biopsies, classified by the technique and/or size of needle used to collect the tissue sample.
A fine needle aspiration biopsy uses a thin needle to remove a small sample of cells.
A core needle biopsy uses a thicker needle to remove a larger sample of tissue. This is usually the preferred biopsy technique for finding out whether an abnormality on a physical examination or an imaging test is cancer. A vacuum-assisted biopsy removes several large cores of tissue. Local anesthesia (medication to block the awareness of pain) is used to lessen a patient’s discomfort.
Image-guided biopsy is used when a distinct lump can't be felt, but an abnormality is seen with an imaging test, such as a mammogram. During this procedure, a needle is guided to the location with the help of an imaging technique, such as mammography, ultrasound, or MRI. A stereotactic biopsy is done using mammography to help guide the needle. A small metal clip may be put into the breast to mark where the biopsy sample was taken, in case the tissue is cancerous and more surgery is needed. An image-guided biopsy can be done using a fine needle, core, or vacuum-assisted biopsy (see above), depending on the amount of tissue being removed. Imaging tests may also be used to help do a biopsy on a lump that can be felt, in order to help find the best location.
A surgical biopsy removes the largest amount of tissue. This biopsy may be incisional (removal of part of the lump) or excisional (removal of the entire lump). Because definitive surgery is best done after a cancer diagnosis has been made, a surgical biopsy is usually not the recommended way to diagnose breast cancer. Most often, non-surgical core biopsies are recommended to diagnose breast cancer. This means that only one surgical procedure is needed to remove the tumor and to take samples of the lymph nodes.
If cancer is diagnosed, surgery is needed to remove the cancer in the breast and evaluate the lymph nodes for cancer (called a sentinel lymph node biopsy), although treatment may be given first (called neoadjuvant therapy). The goal is to achieve clear surgical margins (no cancer cells at the edge of the tissue removed during surgery). If there is cancer in the lymph nodes, the cancer is called lymph node-positive breast cancer (or node-positive, for short); if there is no cancer in the lymph nodes, the cancer is called lymph node-negative breast cancer (or node-negative, for short).
Tumor features. Examination of the tumor under the microscope determines if it is invasive or in situ; ductal or lobular; the grade (how different the cancer cells look from healthy cells); and whether the cancer has spread to the lymph nodes. The margins (edges) of the tumor are also examined and their distance from the tumor is measured.
Molecular testing of the tumor
Your doctor may recommend additional laboratory tests on your tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests will help your doctor recommend treatment.
Estrogen receptor (ER) and progesterone receptor (PR) tests. Breast cancer cells with these receptors depend on the hormones estrogen and/or progesterone to grow. The presence of these receptors helps determine both the patient’s risk of recurrence and the type of treatment will be most likely to prevent recurrence. Generally, hormonal therapy works well for ER-positive or PR-positive tumors, but chemotherapy is also used in specific situations. About 75% to 80% of breast cancers have estrogen and/or progesterone receptors.
HER2 tests. About 20% to 25% of breast cancers have an increase in the number of copies of a gene called the human epidermal growth factor receptor (HER2). This is called HER2-positive cancer. The gene makes a protein which is found on the cancer cell and is important in tumor cell growth; these types of cancers usually grow more quickly. The HER2 status helps determine whether a certain type of drug, such as trastuzumab (Herceptin), lapatinib (Tykerb), pertuzumab (Perjeta), or trastuzumab emtansine (TDM-1) might help treat the cancer. In addition, about 50% of HER2-positive tumors also have other positive hormone receptors and can benefit from both types of therapy.
If a person’s tumor does not have ER, PR, and/or HER2, the tumor is called triple-negative. Triple-negative breast cancers make up about 15% of invasive breast cancers and are the most common type diagnosed in women with BRCA1 mutations. This type of breast cancer usually grows and spreads more quickly. Triple-negative breast cancer seems to be more common among younger women, particularly younger black women.
Ki67. How quickly a cell divides into two cells, called tumor proliferation, can be measured in a tumor sample and is referred to as Ki67 or MIB1. How well chemotherapy works to treat a tumor has been linked with how quickly tumor cells grow and divide. Chemotherapy seems to work best for tumors cells that grow more quickly and hormonal therapy tends to work better for slower growing cancers. Ki67 is not used in many hospitals because the results depend on the laboratory doing the testing or how the testing is done. However, there has been interest in standardizing the testing methods so measuring tumor proliferation is becoming more common.
Genetic testing of the tumor. Tests that look at the biology of the tumor are commonly used to understand more about a woman’s breast cancer, particularly for cancers that have not spread to other organs. The tests below look at the genes in the tumor sample (not a person’s inherited genes) to help predict the risk of cancer recurrence, and to help choose treatment. They are usually done after surgery. A person with a higher risk of recurrence will likely need chemotherapy, while a person with a lower risk of recurrence can possibly avoid these treatments and their potential side effects. For more information about genetic tests, what they mean, and how the results might affect your treatment plan, talk with your doctor.
Oncotype Dx™ (the recurrence score) is a test that evaluates 16 cancer-related genes and five reference genes to estimate the risk of distant recurrence (return of the cancer in a place other than the breast) within 10 years after diagnosis for women with stage I or stage II, node-negative, ER-positive breast cancer treated with hormonal therapy alone. It is mainly used to help make decisions about whether chemotherapy should be added to a person’s treatment. Recent research suggests that this test might be useful to decide about use of chemotherapy in node-positive disease in some situations.
Mammaprint™ is another, similar test using information about 70 genes to predict the risk of the cancer coming back for early-stage, low-risk breast cancer. It is approved by the U.S. Food and Drug Administration (FDA) for estimating the risk of recurrence in early-stage breast cancer, but has not been studied specifically as a way to predict if chemotherapy will work.
The doctor may also need to do several types of blood tests to learn more about the cancer:
Serum chemistry. These tests are often done to look at blood electrolytes (minerals in your body, such as potassium and calcium) and enzymes (specialized proteins) that can be abnormal if cancer has spread. However, many noncancerous conditions can cause changes in these tests, and they are not specific to cancer.
Alkaline phosphatase is an enzyme that can be associated with disease that has spread to the liver, bone, or bile ducts.
Blood calcium levels can be high if cancer has spread to the bone.
Total bilirubin count and the enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) evaluate liver function. High levels of any of these substances can indicate liver damage, a sign that the cancer may have spread to that organ.
Blood tumor marker tests. A serum tumor marker (also called a biomarker) are proteins found in a person's blood that can be associated with cancer. High levels of a serum tumor marker may be due to cancer or a noncancerous condition. Tumor marker testing is not recommended for early-stage breast cancer (and the markers are not usually high), but they may be useful to monitor recurrent or metastatic disease.
The doctor may recommend additional tests (depending on the patient’s medical history, symptoms, how much the disease has grown in the breast and lymph nodes, and the results of the physical examination) to evaluate the stage of the cancer. Many of these tests may not be done until after surgery. These tests are generally only recommended for patients with later stage disease.
An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray may be used to look for cancer that has spread from the breast to the lungs.
A bone scan may be used to look for spread to the bones. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. Some cancers may not show up on bone scan.
A computed tomography (CT or CAT) scan may be used to look for tumors in organs outside of the breast, such as the lung, liver, bone, and lymph nodes. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium is injected into a patient’s vein to provide better detail.
A positron emission tomography (PET) scan may be used to find out whether the cancer has spread to organs outside of the breast. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of radioactive sugar (glucose) is injected into a patient’s body. This substance is absorbed more by organs and tissues that use the most energy. Because cancer tends to use energy actively (called metabolically active), it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. A combination PET/CT scan may also be used to better understand if metabolically active areas could be cancer.
Staging is a way of describing where the cancer is located, how much the cancer has grown, and if or where it has spread. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
The most commonly used tool that doctors use to describe tumor stage is the TNM system. This system judges three factors: the size of the tumor itself, the presence of cancer in the lymph nodes where the cancer cells often first travel, and whether the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. In breast cancer, there are five stages: stage 0 (zero), which is noninvasive ductal carcinoma in situ (DCIS), and stages I through IV (one through four), which are used for invasive breast cancer. Stage provides a common way of describing the cancer so doctors can work together with the patient to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located?(Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
There are two types of TNM staging for breast cancer. First, the clinical stage is based on the results of tests done before surgery, such as a physical examination, x-rays, CT scans, and MRI tests. Then, the pathologic stage is assigned based on information found during surgery plus the laboratory results (pathology) of the breast tissue and any lymph nodes removed during surgery. It is usually determined several days after surgery when the results from testing the tumor and lymph nodes are ready. In general, more importance is placed on the pathologic stage than the clinical stage.
Tumor. Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail.
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of cancer in the breast.
Tis: Refers to carcinoma (cancer) in situ. The cancer is confined within the ducts or lobules of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:
Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it can later develop into an invasive breast cancer. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.
Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.
Tis (Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is associated with another invasive breast cancer. If there is also an invasive breast cancer present, it is classified according to the stage of the invasive tumor.
T1: The invasive part of the tumor in the breast is 20 millimeters (mm) or smaller in size at its widest area (a little less than an inch). This stage is then broken into three substages depending on the size of the tumor, called T1a (tumor is larger than 1 mm, but 5mm or smaller), T1b (tumor is larger than 5 mm, but 10 mm or smaller), and T1c (tumor is larger than 10 mm, but 20 mm or smaller).
T2: The invasive part of the tumor is larger than 20 mm but not larger than 50 mm.
T3: The invasive part of the tumor is larger than 50 mm.
T4: The tumor has grown into the chest wall (called T4a) and/or to the skin (called T4b). If there are signs of both, it is called T4c, and inflammatory breast cancer is called T4d.
Node. The “N” in the TNM staging system stands for lymph nodes. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. As explained above, if the doctor evaluates the lymph nodes before surgery, based on other tests and/or a physical examination, a letter “c” (for “clinical” staging) is placed in front of the “N.” If the doctor evaluates the lymph nodes after surgery, which is a more accurate assessment, a letter “p” (for “pathologic” staging) is placed in front of the “N.” The information below describes the pathologic staging.
NX: The lymph nodes cannot be evaluated.
N0: No cancer was found in the lymph nodes.
N0(i+): When very small areas of “isolated” tumor cells are found in a lymph node (less than 0.2 mm or less than 200 cells), the nodes are still called N0, but an “i+” is also listed.
N1mic: Cancer in the lymph nodes is larger than 0.2 mm but less than 2 mm in size (microscopic).
N1: The cancer has spread to one to three axillary lymph nodes under the arm. This category can include positive internal mammary lymph nodes (found under the sternum or breastbone) if found during a sentinel lymph node procedure and not otherwise clinically detected.
N2: The cancer has spread to four to nine lymph nodes under the arm (called N2a), or to clinically apparent internal mammary lymph nodes (lymph nodes under the sternum on the inside of the chest, called N2b) without spread to the axillary nodes.
N3: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes (located under the clavicle, or collarbone); this is called N3a. Or, the cancer has spread to the internal mammary nodes with axillary node involvement (N3b) or to the supraclavicular (located above the clavicle) lymph nodes (N3c).
If there is cancer in the lymph nodes, knowing how many lymph nodes are involved, and where they are helps doctors to plan treatment. The pathologist can find out the number of axillary lymph nodes that contain cancer after they are removed during surgery. It is not common to remove the supraclavicular or internal mammary lymph nodes during surgery. If there is cancer in these lymph nodes, treatment other than surgery, such as radiation therapy, chemotherapy, and hormonal therapy is used to control the disease.
Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: Distant spread cannot be evaluated.
M0: The disease has not metastasized.
M0 (i+): There is no clinical or radiographic evidence of distant metastases, but microscopic evidence of tumor cells is found in the blood, bone marrow, or other lymph nodes that are no larger than 0.2 mm in a patient without other evidence of metastases.
M1: There is evidence of metastasis to another part of the body (breast cancer cells growing in other organs).
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications.
Stage 0: Stage zero (0) describes disease that is only in the ducts and lobules of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called noninvasive cancer (Tis, N0, M0).
Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).
Stage IB: Cancer has spread only to the lymph nodes, where it is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller (T0 or T1, N1mic, M0).
Stage IIA: Any one of these conditions:
There is no evidence of a tumor in the breast, but the cancer has spread to the axillary lymph nodes but not to distant parts of the body. (T0, N1, M0).
The tumor is 20 mm or smaller and has spread to the axillary lymph nodes (T1, N1, M0).
The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the axillary lymph nodes (T2, N0, M0).
Stage IIB: Either of these conditions:
The tumor is larger than 20 mm but not larger than 50 mm and has spread to one to three axillary lymph nodes (T2, N1, M0).
The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0, M0).
Stage IIIA: The cancer of any size has spread to four to nine axillary lymph nodes, but not to other parts of the body (T0, T1, T2 or T3, N2, M0). Stage IIIA may also be a tumor larger than 50 mm that has spread to one to three lymph nodes (T3, N1, M0).
Stage IIIB: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but it has not spread to other parts of the body (T4; N0, N1 or N2; M0).
Stage IIIC: A tumor of any size that has not spread to distant parts of the body but has spread to 10 or more axillary lymph nodes or the lymph nodes in the N3 group (any T, N3, M0).
Stage IV (metastatic): The tumor can be any size and has spread to another organ (bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1). Metastatic cancer spread is found when the cancer is first diagnosed about 5% to 6% of the time. Most commonly, metastatic breast cancer is found after a previous diagnosis of early-stage breast cancer.
Recurrent: Recurrent cancer is cancer that comes back after treatment, and can be either local or distant or both. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.
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