STAGE 2 (INVASIVE) BREAST CANCER

Return to invasive breast cancer page

If your cancer is a (clinical) Stage 2, it means that the tumor in your breast is a bit larger, or that there are between 1-3 lymph nodes with cancer in them, even though the tumor in your breast is still small. There is no evidence of disease spread to organs beyond the breast and the lymph nodes. Using the TNM staging, the possible combinations within stage 2 are:

  • Stage IIA: T0 or T1, N1 (but not N1mi), M0 / T2, N0, M0
  • Stage IIB: T2, N1, M0 / T3, N0, M0

Your doctors use their best estimate about the tumor size and the presence of cancer in lymph nodes or elsewhere to come up with the “clinical” stage, in order to make appropriate treatment plans prior to the surgery. Once the surgery has been done, these estimates are re-evaluated, based on actually looking at these tissues under the microscope. So the clinically estimated stage may change based on the “pathologic” findings. You can learn more about staging breast cancer by following this link to our “Staging” page.

As you might expect, the possibility of cancer coming back after treatment is higher for Stage 2 cancers than for Stage 1 cancers. But the prognosis is still good. The treatment almost always includes surgery, chemotherapy, and radiation therapy.

One of the first decisions your surgeon will need to make with you is whether to plan the surgery first, or whether to consider giving you chemotherapy first. Many women are not aware that there are lots of reasons to consider delaying the surgery until after chemotherapy; I’ll explain this in more detail below. I would say though, that in general, if there is enough information at diagnosis to know that chemotherapy will be included in the treatment, it may be preferable to use chemotherapy first, and then doing the surgery.

At DeKalb Surgical, for Stage 2 cancers, many patients are offered a Roundtable Consultation as soon as the diagnosis of cancer is made. At this unique meeting, a multidisciplinary team of doctors and our nurse navigator will all meet together with you simultaneously, in order to come to a unified treatment plan, customized to your specific situation, to offer you the greatest likelihood of a cure. Since we have developed a variety of effective weapons for breast cancer, including surgery, radiation therapy, hormonal treatments, and chemotherapy, we want the doctors who specialize in each of the treatment modalities to meet and work together to recommend the best sequence of treatments. We don’t have to use all of these modalities in every case, but it is best to decide up front, what the best plan would be, and in which order, with input from the entire team, including you, the patient. The Roundtable Consultations assures that you get an individually tailored plan, agreed upon by all the specialists and by you as well.

In addition to the clinical stage, your doctors will consider the following factors in making a treatment plan: your age, your personal and family history of other breast cancers, sensitivity of your cancer to estrogen, whether your cancer has “overexpression” of HER2, findings on your mammogram, and possibly some other imaging studies as well, and your overall health, paying particular attention to any heart or lung disabilities. There may be other factors of importance in individual cases. Since all of these factors can affect the final recommendations, it is difficult to summarize the treatment possibilities here. For purposes of the Roundtable Consultation, you are typically given a broad overview of what the best plan seems to be, focusing on the sequence of treatments, and expected duration (for example, chemotherapy for 4 cycles lasting a total of about three months, then breast conserving surgery and lymph node dissection [removal], then radiation therapy for 6 weeks, then hormone blocking treatment).

Surgery plays an important role in Stage 2 breast cancer, although chemotherapy needs to be considered in most cases as well. With these more advanced cancers, the order of treatment more often begins with chemotherapy. For this group of women, there is no consensus among physicians about using chemotherapy first or surgery first. The DeKalb Surgical doctors typically support the use of chemotherapy before surgery. This method allows us to see that in your individual case, the selected chemotherapy is effective in shrinking the tumor down in size. Not only does this let us know with certainty that your cancer is sensitive to the selected treatment, the shrinking tumor makes it easier to surgically remove it with clear margins later on. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL the remaining cancer has disappeared. These patients have a particularly good prognosis.

Lumpectomy can usually be considered instead of mastectomy for Stage 2 breast cancer. Other terms that might be used are “breast-conserving surgery”, or “breast conservation”. As long as we can get “clear margins” around the cancer then a mastectomy is not needed. Since the Stage 2 category includes larger tumors than those in the Stage 1 category, more women in this group may need a mastectomy, but it’s important to know that lumpectomy is still likely to be possible, particularly if chemotherapy is given first, and there is a good “response” to this treatment, with a decrease in tumor size.

A lumpectomy removes enough tissue around the cancer so that no cancer cells are seen along the margins of the removed tissue. I like to use the analogy of a hard-boiled egg. The yellow yolk (which represents the cancer) on the inside should have “egg white”, or normal breast tissue, on all sides, such that that yellow egg yolk is not seen anywhere on the outside surfaces of the egg. Now in actuality, cancer cells aren’t yellow like an egg yolk, and one cannot always tell during the surgery that the margins are clear. But fortunately in over 90% of the cases at DeKalb Surgical, the margins are clear with just one procedure. At many centers, as many as 30-40% of women with invasive cancer need a second procedure to get “clear margins”.

The “sentinel node biopsy” part of the operation involves a second small incision under your arm (called the axilla), combined with an injection of dye in your breast, usually at the nipple. The idea is to check to see if there is any cancer spread to the lymph nodes. The dye injection allows the surgeon to identify the first nodes to receive any lymph flow from the breast; if any cancer cells have spread to the lymph nodes, they almost certainly will be found in these first, or sentinel, nodes. This method allows the surgeon to leave all of the other lymph nodes alone, unless cancer cells are seen in the sentinel nodes.

If it is known that there are cancer cells in even just one of the lymph nodes under your arm, then in almost all cases your doctor will recommend removing all the lymphatic tissue under your arm, rather than just the sentinel nodes. this is called a “complete axillary dissection”.

Following lumpectomy, radiation is almost always required in order to minimize the possibility of recurrence. Decades ago, when mastectomy was the only surgical option, several national and international studies were done to determine if women could undergo a less radical operation. Although these studies clearly showed that women did just as well long term with lumpectomy instead of mastectomy, radiation therapy was needed to keep the local recurrence rate to a minimum. In these studies, women who had lumpectomy without radiation therapy had cancer come back in the breast about 30% of the time. And so, these days when lumpectomy is considered the preferred surgical option, it is almost always considered as part of a “package deal”, with radiation therapy to follow.

Radiation therapy for breast cancer has traditionally been given as several daily brief treatments to the entire breast, usually taking about 6 weeks. It is given this way in order to minimize the side effects to the skin. The effect of the radiation on the breast tissue is “cumulative”, meaning that the total required dose can be divided into very small daily doses, and as long as the sum of the small doses equals the required total dose, you will achieve the desired outcome. If higher daily doses would be given instead, the skin would get radiation burns. Even with the small doses given, this can sometimes be a problem. The radiation therapy physician will discuss these possibilities with you, and will monitor you for any evidence of problems during the six weeks of treatment.

There is a new way to give the radiation therapy after lumpectomy, which is an option for some women, called partial breast irradiation therapy. This method can be completed with in just 5 days, with two daily treatments each day. The radiation is given by placing a tiny “radioactive seed” inside the breast briefly for each treatment. This method almost completely eliminates the risk of skin damage, and this is why the treatment can be completed so much faster. This technique has been used at DeKalb Surgical since 2006 for selected women, so we have lots of experience with it. You can read more about this treatment option on our MammoSite page. For Stage 2 breast cancers, this might not be an option; your surgeon can discuss this with you.

Chemotherapy is a standard part of treatment for most women with Stage 2 breast cancer, although the decision for chemotherapy is based on several different factors. Your age and general health, including any other major medical problems must be considered. The characteristics specific to your cancer may indicate that chemotherapy won’t have much impact. Each woman brings her own priorities and concerns regarding chemotherapy, and these are of course considered by your doctors. There are a number of ways to try to predict your risk for recurrence, and depending on how high or low that risk is, each individual woman may make their own choice.

In some cases, your doctors may recommend a mastectomy instead of lumpectomy. This might be because the tumor size is big compared to the size of your breast, so that the cosmetic result following lumpectomy might be poor. There may be worrisome calcifications scattered through all of your breast, which can be worrisome for other tiny cancer spots. You may have had two separate cancers found in different parts of your breast. If you have had cancer come back after previous lumpectomy and radiation therapy, you almost always will need a mastectomy. If you test positive for one of the BRCA mutations, you will probably be advised to have bilateral mastectomy. And it may be that as you consider your options, mastectomy may just seem to be a better choice. But in most cases, your surgeon should at least be offering breast conservation, unless it is made very clear why it would not be appropriate.

If you do have a mastectomy, in most cases, a breast reconstruction is an option. In many cases this can be done immediately. In other words, you have your surgery for the mastectomy, and you wake up afterward with the reconstructed breast. Not all women choose to undergo breast reconstruction, or may choose to delay the reconstruction until a later date. The discussion about what is best for you can get a bit complicated, and is best done with your surgeon and plastic surgeon. There are many options available these days, including the use of some tissue from other adjacent parts of your body, silastic or saline implants, or a combination of these. A common reconstruction method is to use fatty tissue and muscle tissue from the abdominal wall, which is rotated upward to replace the breast mound. Surgeons may leave the skin “envelope” of your breast (a “skin-sparing mastectomy”), and then re-fill the skin with the transferred tissue or with an implant. This method seems to give better cosmetic results in general.

It is important to know that if radiation therapy is necessary, it can affect the cosmetic results of a reconstruction, so if you are going to need radiation even after a mastectomy, your doctors should discuss the possible added risks.

Your cancer tissue will be tested for any sensitivity to hormones. The two routine tests are “estrogen receptor (ER)” and “progesterone receptor (PR)”. The ER is considered the more important one, but basically if either or both of these is “positive (+)”, then it means the cancer cells can be stimulated by estrogen. There are a number of drugs which can block the effects of estrogen on any cancer cells remaining in the body, and so one of these drugs is routinely used for ER+ cancers. But, these drugs might blunt the effectiveness of chemotherapy or radiation therapy if given at the same time. For this reason, any hormone blocking treatment is usually held until after the other treatments (surgery, radiation therapy, chemotherapy) are completed. The estrogen blocking drugs include tamoxifen, Arimidex, Femara, and Aromasin. Tamoxifen works differently from the other three, by blocking the receptors for estrogen on the breast cells. The other three are all in the class of drugs call “aromatase inhibitors”. These act by blocking the production of estrogen in the body. An important thing to understand about these drugs is that they do not inhibit production of estrogen in functional ovaries. For this reason, aromatase inhibitors are not effective in women before menopause. And so, for women who have not yet gone through menopause, tamoxifen is the only tried and true option for hormone-blocking treatment in ER+ women.

Return to top

 

Your cancer might be sent for a test called OncotypeDX Recurrence Score (this is only appropriate in patients with cancers sensitive to estrogen (ER positive). This test has been shown to do a better job of knowing, or predicting, whether there would be any benefit to giving chemotherapy. If you want more information about this, follow this link.

The choice of chemotherapy is dependent on a number of factors. We can now test your cancer to see in advance if it will be sensitive to certain types of chemotherapy, so it is critical to do these tests before deciding on which specific drugs to use. Whatever drugs are recommended, they are typically given in “cycles”. A “cycle” is typically a two or three week interval. Carefully calculated doses of the selected drugs are given at the beginning of the cycle, and you are monitored for side effects as the drugs work on the cancer. The drugs also affect normally dividing cells in your body, and this is the source of the potential side effects. The cells in the body that are dividing the most include blood cells in the bone marrow, hair cells, and the cells lining the digestive tract, from the mouth all the way through the rectum. Knowing this, it is no surprise that the side effects include anemia, and other changes in the blood, like lowered white blood cell count, hair loss, and nausea and vomiting. Fortunately, oncologists are good at preventing or at least managing these potential side effects in most cases. Prior to initiating the treatments, your oncologist will no doubt discuss the potential side effects with you, and any alternative regimens that might be used. The various chemotherapy drugs have different potential side effects, so you should discuss these issues with them prior to your starting your treatment.

One routine assay done on breast cancers is called the HER2 assay. We have learned that when this gene is “overexpressed” in a cancer, it is more likely to act aggressively, by spreading to other organs. But we have also discovered a drug, which was specifically designed to block this protein’s function is very effective in decreasing the aggressiveness of these cancers. Only about 15% of breast cancers have this genetic dysfunction, but if your cancer is “HER2 positive”, you likely will be advised to receive this specific chemotherapy, called Herceptin, in addition to some other drugs. The Herceptin is usually given in cycles over the entire first year following the initial treatment.

Whether surgery is done before or after chemotherapy, breast conservation is typically very desirable. The surgery for breast conservation is usually called “lumpectomy and axillary dissection”, or “partial mastectomy and axillary dissection”, and almost always requires radiation therapy afterward.

In addition to the lumpectomy or mastectomy, the lymph nodes under the arm will be removed, or in some cases, just sampled. In Stage 2, some patients will already be known to have some cancer cells in at least one or more of the lymph nodes. If it is already known that there is some involvement of some lymph nodes, it is almost always appropriate to remove all of the fatty tissue under the arm (the axilla) where the lymph nodes are found. This tissue is sent to the pathology department and then placed in formaldehyde, which “fixes” or “preserves” the tissue, to keep it from decaying. The tissue is then dissected to find out how many lymph nodes are contained in it, and how many of the lymph nodes have cancer. This information is then used to update the staging of the cancer.

Radiation therapy is virtually always used after lumpectomy, to decrease the likelihood of recurrence of cancer in the breast. And in Stage 2 cancers, even after mastectomy, radiation therapy may be recommended for treatment of the chest wall.

Return to top

Return to Invasive Breast Cancer Page

Return to Breast Cancer Home Page

Other Resources

You can find a comprehensive educational patient resource on the National Comprehensive Cancer Network website.  There is a direct link to their online “virtual book” for with Stage I or II  breast cancer.