Breast Cancer

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    Stage I

    These cancers are still relatively small and have not spread to the lymph nodes or elsewhere.

    Local therapy: Stage I cancers can be treated with either breast-conserving surgery (lumpectomy, partial mastectomy) or modified radical mastectomy. The lymph nodes will also need to be evaluated, with a sentinel lymph node biopsy or an axillary lymph node dissection. Breast reconstruction can be done either at the same time as surgery or later.

    Radiation therapy is usually given after breast-conserving surgery. Women who may consider breast-conserving surgery without radiation therapy typically have all of the following:

    they are age 70 years or olderthey have a tumor 2 cm or less across that has been completely removedthey have a tumor that contains hormone receptors and hormone therapy is givennone of the lymph nodes that were removed contained cancer

    Although some women who do not meet these criteria may be tempted to avoid radiation, studies have shown that not getting radiation increases the chances of the cancer coming back.

    Adjuvant systemic therapy: Most doctors will discuss the pros and cons of adjuvant hormone therapy (either tamoxifen or an aromatase inhibitor) with all women who have a hormone receptor–positive (estrogen or progesterone) breast cancer, no matter how small the tumor. Women with tumors larger than 0.5 cm (about 1/4 inch) across may be more likely to benefit from it.

    If the tumor is smaller than 1 cm (about 1/2 inch) across, adjuvant chemotherapy is not usually offered. Some doctors may suggest it if a cancer smaller than 1 cm has any unfavorable features (such as being high-grade, estrogen receptor–negative, HER2-positive, or having a high score on one of the gene panels). Adjuvant chemotherapy is usually recommended for larger tumors.

    For HER2-positive cancers larger than 1 cm across, adjuvant trastuzumab (Herceptin) is usually recommended as well.
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    Stage 1 is an early stage of the disease, in which the tumor measures up to two centimeters and no lymph nodes are involved.

    Women with early stage breast cancer may have breast-sparing surgery (e.g., lumpectomy) followed by radiation therapy as their primary local treatment, or they may have a mastectomy (removal of the entire breast) with or without breast reconstruction to rebuild the breast. Sometimes radiation therapy is also given to the chest wall after surgery. In addition, chemotherapy and/or hormone therapy may also be given to try to destroy any remaining cancer cells and prevent the breast cancer from recurring.
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    Stage 1 is divided into two categories:
    • Stage 1A: The tumor measures 2 cm or smaller (about the size of a pea or shelled peanut), and has not spread outside the breast.
    • Stage 1B: Small clusters of cancer cells measuring no more than 2 mm, are found in the lymph nodes, and either there is no tumor inside the breast, or the tumor is small, measuring 2 cm or less.
    The survival rate for stage 1A breast cancer may be slightly higher than for stage 1B. However, all women with stage 1 breast cancer are considered to have a good prognosis.

    At stage 1, TNM designations help describe the extent of the disease. (In the TMN system, T describes the size of the original tumor; lymph node -- N -- indicates whether the cancer is present in the lymph nodes; and metastasis -- M -- refers to whether cancer has spread to other parts of the body.) For example, there may or may not be cancer cells in the lymph nodes, and the size of the tumor may range from 1 cm to 2 cm. Most commonly, stage 1 breast cancer is described as:
    • T: T1, T2, T3 or T4, depending on the size and/or extent of the primary tumor.
    • N0: Usually, cancer has not spread to the lymph nodes
    • M0: The disease has not spread to other sites in the body
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    A Surgery, answered on behalf of
    The stages of breast cancer are determined by the size of the tumor and if it has spread to underarm lymph nodes or other areas of the body. The stages include:
    • Stage 0: noninvasive breast cancer.
    • Stage I: invasive cancer confined to the breast with a tumor up to 2 cm in size. No spread to the underarm lymph nodes.
    • Stage II: invasive cancer with a tumor 2 to 5 cm in size or with a tumor less than 5 cm in size with spread to the underarm lymph nodes.
    • Stage III: invasive cancer with a tumor bigger than 5 cm in size, or with spread to multiple underarm lymph nodes, skin or muscle.
    • Stage IV: invasive breast cancer that has spread to other organs such as the lungs, liver, bone or brain.
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    Stage IV cancers have spread beyond the breast and lymph nodes to other parts of the body. Although surgery and/or radiation may be useful in some situations, they are very unlikely to cure these cancers, so systemic therapy is the main treatment. Depending on many factors, this may consist of hormone therapy, chemotherapy, targeted therapies such as trastuzumab (Herceptin) or bevacizumab (Avastin), or some combination of these treatments.
    Trastuzumab may help women with HER2-positive cancers live longer if it is given with the first chemotherapy for stage IV disease. It is not yet known whether it also should be given at the same time as hormone therapy, or how long a woman should remain on therapy.
    Bevacizumab, a drug that blocks new tumor blood vessel growth, has been shown to slow the progression of advanced breast cancer when it is combined with the chemotherapy drug paclitaxel (Taxol).
    All of the systemic therapies given for breast cancer -- hormone therapy, chemotherapy, and the newer targeted therapies -- have potential side effects, which were described in previous sections. Your doctor will explain to you the benefits and risks of these treatments before prescribing them.
    Radiation therapy and/or surgery may also be used in certain situations, such as to treat a small number of metastases in a certain area, to prevent bone fractures or blockage in the liver, or to provide relief of pain or other symptoms. If your doctor recommends such local treatments, it is important that you understand their goal -- whether it is to try to cure the cancer or to prevent or treat symptoms.
    In some cases, regional chemotherapy (where drugs are delivered directly into a certain area, such as the fluid around the brain) may be useful as well.
    Treatment to relieve symptoms depends on where the cancer has spread. For example, pain from bone metastases may be treated with external beam radiation therapy and/or bisphosphonates such as pamidronate (Aredia) or zoledronic acid (Zometa). Most doctors recommend bisphosphonates (along with calcium and vitamin D) for all patients whose breast cancer has spread to their bones. (For more information about treatment of bone metastases, see the American Cancer Society document, Bone Metastasis, available at or by calling 1-800-227-2345.)
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    In stage 4 (metastatic), the cancer has spread beyond the breast, underarm and internal mammary lymph nodes to other parts of the body near to or distant from the breast. The tumor may have spread to the supraclavicular lymph nodes (nodes located at the base of the neck, above the collarbone), bones, liver, lungs, skin or brain.

    Women with metastatic breast cancer will receive treatment based on where the cancer has spread. The bone is the most common site of spread from breast cancer. Treatments for metastatic breast cancer to bone may include orthopedic oncology, hormone therapy, chemotherapy, targeted therapy, radiation therapy or a combination of treatments.
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    At stage 4, TNM designations help describe the extent of the disease. (In the TMN system, T describes the size of the original tumor; lymph node -- N -- indicates whether the cancer is present in the lymph nodes; and metastasis -- M -- refers to whether cancer has spread to other parts of the body.) Higher numbers indicate more extensive disease. Most commonly, stage 4 breast cancer is described as:
    • T: T1, T2, T3 or T4, depending on the size and/or extent of the primary tumor.
    • N1: Cancer has spread to the lymph nodes
    • M1: The disease has spread to other sites in the body
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    Women who are diagnosed with stage 4 breast cancer have several treatment options. Because the cancer has spread to other parts of the body, focused treatments like surgery and radiation are not an option. Stage 4 breast cancer treatments may include:
    • Chemotherapy: Chemotherapy is the main treatment for stage 4 breast cancer. These drugs can kills cancer cells and slow down the growth of the cancer. Chemotherapy is often given in combination with hormone therapy or immunotherapy.
    • Hormone Therapy: For women whose cancer cells test positive for estrogen and/or progesterone receptors, hormonal therapy can help eliminate cancer cells from the body. These drugs prevent the tumor from getting the hormone it needs to grow. For women with stage 4 breast cancer, hormone therapy is given in combination with chemotherapy.
    • Immunotherapy: When the cancer cells contain excess amounts of the HER2 protein receptors, immunotherapy with an anti-HER2 drug may be recommended in combination with chemotherapy to help kill cancer cells and slow down the growth of the cancer.
    • Clinical trials: Many clinical trials are open to women with stage 4 breast cancer. Enrolling in a clinical trial may give you access to new therapies. Your doctor can provide information about ongoing studies that may be available to you.
    • Additional care: Many drugs are available to help ease pain and the side effects of stage 4 breast cancer treatment. Your doctor can discuss treatments for nausea, vomiting, fatigue and infections.
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    A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. The most common system used to describe the stages of breast cancer is the
    American Joint Committee on Cancer (AJCC) TNM system.

    The stage of a breast cancer can be based either on the results of physical exam, biopsy, and imaging tests (called the clinical stage), or on the results of these tests plus the results of surgery (called the pathologic stage). The staging described here is the pathologic stage, which includes the findings after surgery, when the pathologist has looked at the breast mass and nearby lymph nodes. Pathologic staging is likely to be more accurate than clinical staging, as it allows the doctor to get a firsthand impression of the extent of the cancer.

    The TNM staging system classifies cancers based on their T, N, and M stages:

    T stands for tumor (its size and how far it has spread within the breast and to nearby organs).
    N stands for spread to lymph nodes (bean-shaped collections of immune system cells).
    M is for metastasis (spread to distant organs).

    Additional letters or numbers appear after T, N, and M to give more details about the tumor, lymph nodes, and metastasis:

    • The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.
    • The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.
    • The letter M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for example, the lungs or bones.

    Primary tumor (T)
    TX: Primary tumor cannot be assessed.
    T0: No evidence of primary tumor.
    Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass)
    T1: Tumor is 2 cm (3/4 of an inch) or less across.
    T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
    T3: Tumor is more than 5 cm across.
    T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.
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    A , Cardiology (Cardiovascular Disease), answered

    Ductal carcinoma in situ (DCIS) could break the boundary of the milk duct(s) of the breast, spreading into other parts of the breast and beyond to become invasive or infiltrating breast cancer. It's just that it is hard to know which ones are aggressive enough to breakthrough and which ones will have a low risk of ever becoming invasive. It could also take many years to become invasive.