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Because I'm annoyed with teevee representation of how breast cancer works, I'm now making a post about how staging and such actually works, in case anyone is interested, which I will put behind a cut for those of you who are not.
When evaluating breast cancer staging and treatment a few things come into play. Three of the more important factors in prognosis, regardless of staging, are the hormonal/her2 status of the tumor, lymph node involvement, and the grade of the cancer.
If the tumor has estrogen and progesterone receptors, meaning estrogen is what is feeding cancer growth, this points to a better prognosis than if they do not, since medications and surgical options are available that prevent the body from producing estrogen. Her2 is a protein that encourages rapid cell growth and indicates a particularly aggressive cancer, however a drug called Herceptin exists for these patients which significantly improves prognosis. Triple negative (that would be me), means none of these receptors exist, which means none of those treatments are available, and is also usually quite aggressive, so it's got the worst prognosis.
Lymph node involvement. You don't want it. Although the presence of cancer in the axillary lymph nodes is still classified as local disease, it is generally considered the primary factor in predicting future metastasis, since it means the cancer knows how to travel, has already done so, and is active in the lymphatic system which is a direct pipeline to the rest of the body. The fewer lymph nodes involved the better, none being what you really want. I've, um, got two.
Grade refers to the nature and appearance of the cells themselves, which is a good predictor of their behavior. Cells which divide slowly and are close to 'normal' appearance would be a grade 1, and not considered particularly aggressive. Cells which are poorly differentiated and have a high rate of division would be grade 3, and classified as nasty. Grade 2 sitting somewhere in the middle. Mine is borderline grade 2/grade 3 (moderately differentiated, but with a wicked high mitosis rate).
All of those factors can either bump up or reduce your individual place in the overall survival statistics for your particular staging. Frex, the overall survival rate for my staging is around 90 percent, but my individual prognostic factors put me at 75 percent. All tumors are not created equal, and this will often determine whether or not chemotherapy is indicated in borderline cases. So, then, staging goes like this:
Stage 0 (yes, there is a stage 0). This is in situ carcinoma, where the cancer cells are present, but contained entirely within the ducts and have not yet become invasive. Treatment is generally either lumpectomy and radiation (most common), or a mastectomy (people choosing this option at this stage generally have other factors involved, like genetic risk or high grade cells with aggressive features). If estrogen positive, Tamoxifen or other estrogen inhibitor will be given for five years followup. Survival rates are pretty close to 100 percent. If you've caught it this early, you are in very good shape indeed.
Stage I. The cancer has become invasive and is present in the surrounding tissue, but it is less than 2 centimeters in size, and there is no lymph node involvement. Treatment is lumpectomy with radiation, or a mastectomy. Whether or not you get chemotherapy is based on the factors above. Triple negative, Her2 positive, or grade 3 will probably be offered it. A small, hormone positive, low grade tumor will probably not. Five years estrogen inhibitor for hormone positive, and a year of Herceptin if the Her2 positive are the follow up. Overall survival rates are, again, pushing 100 percent at this staging.
Stage IIA (*waves*). The primary tumor is less than 2 centimeters with 1 to 3 axillary lymph nodes involved, or the primary tumor is larger than 2 centimeters but less than 5 centimeters with no lymph nodes involved. Treatment is lumpectomy with radiation, or a mastectomy. Radiation may be indicated even with a mastectomy if there is lymph node involvement, but this is a grey area and will again depend on prognostic factors (it is likely I will get radiation due to the size of the involved nodes). Chemotherapy is pretty much always indicated at this staging unless your other prognostic factors are really, really good. Then any indicated estrogen inhibitors and Herceptin as above. Overall survival rates are 90 percent.
Stage IIB. Larger than 2 cm/less than 5 cm with 1-3 axillary lymph nodes, or larger than 5 cm with no nodes. Treatment is essentially the same as for IIA, but radiation is more likely even with mastectomy, and overall survival rates drop to just under 80 percent.
Stage IIIA. Smaller than 5 cm with 4-9 axillary lymph nodes involved, or larger than 5 cm with any axillary lymph nodes up to 9 involved, or there is involvement of any internal mammary lymph nodes. Lumpectomy may be an option depending on tumor size, but mastectomy is most likely. Neo-adjuvant chemotherapy may be given before to surgery to shrink the cancer. Some form of chemo and radiation either way for definite, and a second round of chemo may follow surgery even for those who had neo-adjuvant treatment. Followup hormonals, herceptin blah blah. Overall survival, 65 percent.
Stage IIIB. Any tumor size with chest wall or skin involvement, or more than 9 axillary lymph nodes. Treatment is the same as for IIIA, overall survival drops to just under 50 percent.
Stage IV. There is any, and I do mean any distant metastasis beyond what's mentioned above, regardless of tumor size or lymph node involvement. At this stage a three millimeter spot on a femur gives you the same eventual outcome as a tumor ridden liver. You just have more time. There is no, I repeat, no cure for stage IV breast cancer. Treatment options shift to managing it as a chronic illness, with the goal of stabilization (or, if you are very lucky periods of remission). Hormone positive and Her2 patients may delay chemotherapy and only take estrogen inhibitors/Herceptin depending on how far it's spread and if it's currently causing life threatening damage to vital organs. Triple negatives generally skip directly to chemotherapy. If there is bone involvement, biophosphonates (the stuff they give you for osteoperosis) can often control/reverse cancer growth there. Radiation can be used to attack specific tumors. Pretty much you play whackamole as new cancer pops up until all available treatments stop working (and they will eventually), and the cancer wins. Five year survival rates are 20 percent, ten year survival rates are...pretty well nonexistent, and even the rare miracle patient making it longer than that will still have cancer somewhere in her body.
So, um, yeah..that's how it works.
When evaluating breast cancer staging and treatment a few things come into play. Three of the more important factors in prognosis, regardless of staging, are the hormonal/her2 status of the tumor, lymph node involvement, and the grade of the cancer.
If the tumor has estrogen and progesterone receptors, meaning estrogen is what is feeding cancer growth, this points to a better prognosis than if they do not, since medications and surgical options are available that prevent the body from producing estrogen. Her2 is a protein that encourages rapid cell growth and indicates a particularly aggressive cancer, however a drug called Herceptin exists for these patients which significantly improves prognosis. Triple negative (that would be me), means none of these receptors exist, which means none of those treatments are available, and is also usually quite aggressive, so it's got the worst prognosis.
Lymph node involvement. You don't want it. Although the presence of cancer in the axillary lymph nodes is still classified as local disease, it is generally considered the primary factor in predicting future metastasis, since it means the cancer knows how to travel, has already done so, and is active in the lymphatic system which is a direct pipeline to the rest of the body. The fewer lymph nodes involved the better, none being what you really want. I've, um, got two.
Grade refers to the nature and appearance of the cells themselves, which is a good predictor of their behavior. Cells which divide slowly and are close to 'normal' appearance would be a grade 1, and not considered particularly aggressive. Cells which are poorly differentiated and have a high rate of division would be grade 3, and classified as nasty. Grade 2 sitting somewhere in the middle. Mine is borderline grade 2/grade 3 (moderately differentiated, but with a wicked high mitosis rate).
All of those factors can either bump up or reduce your individual place in the overall survival statistics for your particular staging. Frex, the overall survival rate for my staging is around 90 percent, but my individual prognostic factors put me at 75 percent. All tumors are not created equal, and this will often determine whether or not chemotherapy is indicated in borderline cases. So, then, staging goes like this:
Stage 0 (yes, there is a stage 0). This is in situ carcinoma, where the cancer cells are present, but contained entirely within the ducts and have not yet become invasive. Treatment is generally either lumpectomy and radiation (most common), or a mastectomy (people choosing this option at this stage generally have other factors involved, like genetic risk or high grade cells with aggressive features). If estrogen positive, Tamoxifen or other estrogen inhibitor will be given for five years followup. Survival rates are pretty close to 100 percent. If you've caught it this early, you are in very good shape indeed.
Stage I. The cancer has become invasive and is present in the surrounding tissue, but it is less than 2 centimeters in size, and there is no lymph node involvement. Treatment is lumpectomy with radiation, or a mastectomy. Whether or not you get chemotherapy is based on the factors above. Triple negative, Her2 positive, or grade 3 will probably be offered it. A small, hormone positive, low grade tumor will probably not. Five years estrogen inhibitor for hormone positive, and a year of Herceptin if the Her2 positive are the follow up. Overall survival rates are, again, pushing 100 percent at this staging.
Stage IIA (*waves*). The primary tumor is less than 2 centimeters with 1 to 3 axillary lymph nodes involved, or the primary tumor is larger than 2 centimeters but less than 5 centimeters with no lymph nodes involved. Treatment is lumpectomy with radiation, or a mastectomy. Radiation may be indicated even with a mastectomy if there is lymph node involvement, but this is a grey area and will again depend on prognostic factors (it is likely I will get radiation due to the size of the involved nodes). Chemotherapy is pretty much always indicated at this staging unless your other prognostic factors are really, really good. Then any indicated estrogen inhibitors and Herceptin as above. Overall survival rates are 90 percent.
Stage IIB. Larger than 2 cm/less than 5 cm with 1-3 axillary lymph nodes, or larger than 5 cm with no nodes. Treatment is essentially the same as for IIA, but radiation is more likely even with mastectomy, and overall survival rates drop to just under 80 percent.
Stage IIIA. Smaller than 5 cm with 4-9 axillary lymph nodes involved, or larger than 5 cm with any axillary lymph nodes up to 9 involved, or there is involvement of any internal mammary lymph nodes. Lumpectomy may be an option depending on tumor size, but mastectomy is most likely. Neo-adjuvant chemotherapy may be given before to surgery to shrink the cancer. Some form of chemo and radiation either way for definite, and a second round of chemo may follow surgery even for those who had neo-adjuvant treatment. Followup hormonals, herceptin blah blah. Overall survival, 65 percent.
Stage IIIB. Any tumor size with chest wall or skin involvement, or more than 9 axillary lymph nodes. Treatment is the same as for IIIA, overall survival drops to just under 50 percent.
Stage IV. There is any, and I do mean any distant metastasis beyond what's mentioned above, regardless of tumor size or lymph node involvement. At this stage a three millimeter spot on a femur gives you the same eventual outcome as a tumor ridden liver. You just have more time. There is no, I repeat, no cure for stage IV breast cancer. Treatment options shift to managing it as a chronic illness, with the goal of stabilization (or, if you are very lucky periods of remission). Hormone positive and Her2 patients may delay chemotherapy and only take estrogen inhibitors/Herceptin depending on how far it's spread and if it's currently causing life threatening damage to vital organs. Triple negatives generally skip directly to chemotherapy. If there is bone involvement, biophosphonates (the stuff they give you for osteoperosis) can often control/reverse cancer growth there. Radiation can be used to attack specific tumors. Pretty much you play whackamole as new cancer pops up until all available treatments stop working (and they will eventually), and the cancer wins. Five year survival rates are 20 percent, ten year survival rates are...pretty well nonexistent, and even the rare miracle patient making it longer than that will still have cancer somewhere in her body.
So, um, yeah..that's how it works.