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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 the cancer
originated, and whether there is any indication
of spread to other organs.
I have found
an analogy helpful to describe to women
this concept of what kind of cancer they have.
It’s kind of like a boxer who will be going into
the ring to fight an unknown opponent, and wants
to know what to expect when he walks in that
ring. The unknown opponent in this example is
like your cancer—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. Someone else
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. For breast cancer,
the most important things are the size of the
cancer and whether there is cancer in the nodes.
So let’s walk
through this step by step. I will start by
showing a table of the most important tests that
are likely to be done to evaluate your cancer,
and then give a more detailed description of
each one.
Probably
the best summary of how to say what kind of
cancer you have is to put the information in
this form:
Invasive or
Non-Invasive
Ductal or Lobular
Clinical or
Pathologic Stage 0,1,2, 3 or 4
Grade 1,2 or 3
ER positive or
negative
HER2 positive
or negative
If you can
already circle one term on each line above, then
you and your doctor have a very good description
of your cancer, and can make informed decisions
about how best to treat it. Other tests may
play a role, but primarily on a tailored
individualized basis.
Scroll below this table for more
detailed information.
|
Tests and
categories to define what kind of cancer you
have |
Description |
How is the
result 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, and then categorized as
Low (1-18), Intermediate (18-31), or High
(>31). This test is only used in cancers
which are estrogen receptor (ER) positive. |
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. If
Recurrence Score is Intermediate, there may
be an advantage for chemotherapy, but we
don’t yet know for sure. |
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If you have
had a biopsy of a lump in your breast, or a
biopsy done because of something seen on
mammogram, and the biopsy showed cancer cells,
then you almost certainly have a 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. He will be
able to see whether there is any 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.
For more information, follow
this link to DCIS.
Your doctor
will make an estimate about the size of the
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, and if
so, this could be an indication that some cancer
cells have already had a chance to 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 the cancer based on how
abnormal in appearance the cancer cells are.
This is called “grading” the cancer. The grade
can be either 1, 2, or 3. The Grade 3 cancers
are considered to be the more aggressive type.
These cancer cells are more bizarre in
appearance, and show evidence of dividing more
rapidly, compared to the Grade 1 cancers.
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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 extra production of a protein called
HER2. This protein is involved in the growth of
breast cancer cells, and patients with “HER2
positive” 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 a chemotherapy drug (Herceptin, or
trastuzamab) that specifically targets the HER2
receptor protein, which is highly effective in
such cases.
Another
exciting new test can be used for cancers that
are specifically estrogen receptor (ER)
positive. The test is called the OncotypeDX
Recurrence Score. This test takes about 2 weeks
to get a result. All tests are done at a
central lab in California. This test should
only be ordered if the result is going to be
used in deciding on the use of chemotherapy.
You can find out more about this test by
following this
link.
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 specifically targets HER2, and
tamoxifen targets the estrogen receptor, we may
find other specific cancer proteins which can be
targeted with specifically designed antibody
drugs.
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