Staging of Breast Cancer

Staging is the process of finding out how widespread a cancer is. The stage of a cancer is the most important factor in considering treatment options. A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread.

Depending on the results of your physical exam and biopsy, doctor may want you to have certain imaging tests such as a chest x-ray, mammograms of both breasts, bone scans, and computed tomography (CT) or magnetic resonance imaging (MRI) scans. Blood tests to evaluate your overall health and help detect whether the cancer has spread to certain organs may also be done.

Pathologic Staging
Breast Cancer staging:
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Recurrent cancer
Breast cancer survival by stage

The most common system used to describe the stages of cancers is the American Joint Committee on Cancer (AJCC) TNM system. This 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 that help fight infections and cancers).

 

M is for metastasis (spread to distant organs).

The approach to staging used here is based on the findings after surgery, when the pathologist has looked at the breast mass and lymph nodes (the pathologic stage).

Additional letters or numbers appear after T, N, and M to provide 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 chest wall under the breast. Higher T numbers indicate 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, or to lymph nodes that are not next to the breast, such as those above the collarbone.

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping to determine your disease stage. This is expressed as stage 0 and in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage).

Breast Cancer T, N, M Categories and Stage Groupings

Primary tumor (T):

Regional (nearby) lymph nodes (N) pathologic staging:

Metastasis (M):

Summary of Breast Cancer Stages

Stage 0: Tis, N0, M0:

Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may take a drug called tamoxifen, which can reduce the risk of developing breast cancer. Others may take part in studies of other promising new preventive treatments. Some women may choose not to have treatment, but to return to the doctor regularly for checkups. And, occasionally, women with LCIS may decide to have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)

Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct to invade the surrounding breast tissue. However, women with DCIS are at an increased risk of getting invasive breast cancer. Some women with DCIS have breast-sparing surgery followed by radiation therapy. Or they may choose to have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Underarm lymph nodes are not usually removed. Also, women with DCIS may want to talk with their doctor about tamoxifen to reduce the risk of developing invasive breast cancer.

Ductal carcinoma in situ (DCIS) is the earliest form of breast cancer. In DCIS, cancer cells are located within a duct and have not invaded the surrounding fatty breast tissue or lobular carcinoma in situ (LCIS), which is sometimes classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. In LCIS, abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules or is Paget disease of the nipple. In all cases the cancer has not spread to lymph nodes or distant sites.

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Stage I: T1, N0, M0:

Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct and invaded nearby tissue. Stage I means that the tumor is no more than about an inch across and cancer cells have not spread beyond the breast. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; or the tumor is between 1 and 2 inches (with or without spread to the lymph nodes under the arm); or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy to the breast, or they may have a mastectomy, with or without breast reconstruction to rebuild the breast. These approaches are equally effective in treating early stage breast cancer. (Sometimes radiation therapy is also given after mastectomy.)

The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.

Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy after primary treatment with surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. If the systemic therapy is given to shrink the tumor before surgery, this is called neoadjuvant therapy. Systemic treatment is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back, in the breast or elsewhere.

The tumor is 2 cm (about 4/5 of an inch) or less in diameter and has not spread to lymph nodes or distant sites.

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Stage IIA: T0, N1, M0 / T1, N1, M0 / T2, N0, M0: No tumor is found in the breast but it is in 1 to 3 axillary lymph nodes, or the tumor is less than 2 cm and has spread to 1 to 3 axillary lymph nodes or found by sentinel node biopsy as microscopic disease in internal mammary nodes but not on imaging studies or by clinical exam, or the tumor is larger than 2 cm in diameter and less than 5 cm but hasn't spread to axillary nodes. The cancer hasn't spread to distant sites.

Stage IIB: T2, N1, M0 / T3, N0, M0:

 The tumor is larger than 2 cm in diameter and less than 5 cm and has spread to 1 to 3 axillary lymph nodes or found by sentinel node biopsy as microscopic disease in internal mammary nodes or the tumor is larger than 5 cm and does not grow into the chest wall and has not spread to lymph nodes. The cancer hasn't spread to distant sites.

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Stage IIIA:

Stage III is also called locally advanced cancer. In this stage, the tumor in the breast is large (more than 2 inches across) and the cancer has spread to the underarm lymph nodes; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.

Inflammatory breast cancer is a type of locally advanced breast cancer. In this type of cancer the breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both. Systemic therapy may be given before local therapy to shrink the tumor or afterward to prevent the disease from recurring in the breast or elsewhere.

T0-2, N2, M0 / T3, N1-2, M0: The tumor is smaller than 5 cm in diameter and has spread to 4 to 9 axillary lymph nodes or found by imaging studies or clinical exam to have spread to internal mammary nodes, or the tumor is larger than 5 cm and has spread to 1 to 9 axillary nodes or to internal mammary nodes. The cancer hasn't spread to distant sites.

Stage IIIB: T4, N0-2, M0: The tumor grown into the chest wall or skin and may have spread to no lymph nodes or as many as 9 axillary nodes. It may or may not have spread to internal mammary nodes. The cancer hasn't spread to distant sites.

Stage IIIC: T0-4, N3, M0: The tumor is any size, has spread to 10 or more nodes in the axilla or to 1 or more lymph nodes under the clavicle (infraclavicular) or above the clavicle (supraclavicular) or to internal mammary lymph nodes, which are enlarged because of the cancer. All of these are on the same side as the breast cancer. The cancer hasn't spread to distant sites.

Inflammatory breast cancer is classified as stage III, unless it has spread to distant organs or lymph nodes that are not near the breast, in which case it would be stage IV.

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Stage IV:

Stage IV is metastatic cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the body.

Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.

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Recurrent Cancer
Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.

Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, the distant recurrence is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments for recurrent cancer.

Source: National Cancer Institute

T0-4, N0-3, M1: The cancer, regardless of its size, has spread to distant organs such as bone, liver, or lung, or to lymph nodes far from the breast.

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Breast Cancer Survival by Stage

The numbers below are based on patients diagnosed from 1995 to 1998 and can be expected to be a little different for women diagnosed more recently. One reason is that the staging system was revised in 2002. Another reason is that treatments have improved since 1998. Because of these improved treatments, the survival rates for women diagnosed now should be better. These numbers come from the American College of Surgeons National Cancer Data Base.

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(Survival rates are not yet available for stage IIIC breast cancer because this stage was defined only a few years ago.)

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates assume that people will die of other causes and compares the observed survival with that expected for people without breast cancer. That means that relative survival only talks about deaths from breast cancer