Your medical notes may have listed a number of codes concerning your diagnosis. Or perhaps you are waiting for further testing and prefer to be well-informed before receiving your results.
The majority of oncologists adhere to the universal TNM staging system. In short, this system uses a scoring system for tumour, (lymph) nodes and metastasis according to biopsy and imaging results.
T stands for tumour. T plus a letter or number describes the size (in centimetres) and location of a tumour. T letter and number systems for breast tumours are:
TX: It is not possible to evaluate the tumour due to a lack of data
T0: No evidence of a primary tumour
Tis: Ductal carcinoma ‘in situ’ (DCIS)
T1: The tumour is local to the breast and:
T1mi: The tumour is less than 0.1 cm
T1a: The tumour is between 0.1 and 0.5 cm
T1b: The tumour is between 0.5 and 1 cm
T1c: The tumour is between 1 and 2 cm
T2: The tumour is between 2 and 5 cm
T3: The tumour is larger than 5 cm
T4: The tumour has spread to areas beyond the breast and surrounding tissues
T4a: The tumour has grown into the chest wall
T4b: The tumour has grown into the skin
T4c: The tumour has grown into the skin and chest wall
T4d: Inflammatory carcinoma
N stands for nodes or lymph nodes and the following codes apply:
NX: Regional (nearby) lymph nodes cannot be evaluated due to lack of data
N0: No spread to regional lymph nodes
N1: Tumour has spread to lymph nodes in the armpit or under the breast and is so small it is not visible
pN1mi: Small groups of more than 200 cancer cells
pN1a: Cancer cells in up to 3 lymph nodes with one larger than 2 mm
pN1b: Small groups of cancer cells under the breast (internal mammary nodes)
pN1c: Small groups of cancer cells in up to 3 lymph nodes in the armpit (axillary nodes) and also in the internal mammary nodes
N2: Tumour has spread to axillary lymph nodes and/or internal mammary nodes and is visible
N2a: Cancer cells in the armpit (axillary) lymph nodes that are fixed to other tissues
N2b: Cancer cells in the internal mammary nodes that can be felt
N3: Tumour has spread to non-regional lymph nodes
N3a: Spread to the collarbone area
N3b: Spread to the armpit and under the breastbone
N3c: Spread to above the collarbone
Finally, M stands for metastasis. The following codes apply:
M0: There is no spread to distant lymph nodes or other organs
cMo(i+): Cancer cells are found in blood, bone marrow of non-regional lymph nodes but not visible on medical imaging
M1: Distant metastasis is present in distant lymph nodes and/or to other organs.
Breast cancer metastasis is most likely to affect the bones, lungs, liver and/or brain. 13
Breast cancer is then further grouped according to TNM results in up to 5 stages. Stage 0 is a carcinoma in site and early cancer stage that sometimes does not require treatment. Stage I (IA or IB) is relatively early non-metastasized breast cancers with no lymph node spread and tumours of less than 2 cm in size. Stage II (IIA and IIB) indicates a tumour of between 2 and 5 cm that is limited to the breast and minimal lymph node spread. Stage III (IIIA and IIIB) indicates axillary and/or internal mammary lymph node involvement with a tumour size of over 5 cm. Some more advanced stage III breast cancers are inoperable. Stage IV indicates metastasis. It should also be mentioned that other prognostic factors are important in breast cancer staging and treatment. These include the presence of HER2 and ER+ (oestrogen positive) cancers, oncotype DX and other computerised tests that measure the risk of your particular type of breast cancer recurring after treatment, and KI 67 status according to an index that is a new, highly sensitive test for predicting how responsive your cancer may be to chemotherapy that can be carried out on biopsy samples.
Additionally, you may have been rediagnosed with recurrent breast cancer after being in remission for a time. Local recurrence refers to cancer reappearing in the same area as the previous cancer, regional recurrence to an area close to the previous cancer, and distant recurrence refers to metastatic breast cancer.
What are breast cancer symptoms?
If you are reading this page, you may have been diagnosed with breast cancer due to the presence of one or more symptoms.
The most common symptoms of breast cancer are:
Skin changes (swelling, redness)
Larger size or change in shape of one or both breasts
Changes in the appearance of one or both nipples
Nipple discharge
Generalised pain of the breast area
Lumps felt during a breast examination
Itchy breasts
Orange-peel type skin on one or both breasts
National screening programs for the detection of breast cancer in the general population are common. Most screenings are for women over 45 years of age, women with a family history of breast cancer, and women with the BRCA1 or BRCA2 gene. Screening involves a mammogram or breast X-ray, although MRI imaging is becoming a more popular option.
Can I prevent breast cancer?
Unfortunately, a number of cancer types run in families. If you are aware of a family member suffering from breast cancer, your risk of developing it is higher. If you have been tested for BRCA1 or BRCA2 genes, this is also the case. Today, many cancer-linked genes can be checked via a simple blood test. If your family history or genetic makeup shows an increased risk of breast cancer you should attend biannual screening and be very aware of the physical signs of this disease.
Non-familial risk factors include alcohol use (younger women who drink alcohol from a young age have increased risk of developing breast cancer), smoking, obesity, short or absent breast-feeding periods, long-term (more than 5 years) hormone replacement therapy and higher levels of radiation exposure.
If you have any of the above risk factors, screening should begin from an earlier age. Remedazo can arrange annual or biannual complete health checks for all ages to ensure peace of mind.
A healthy lifestyle is important in breast cancer prevention. Avoiding obesity or losing weight, not smoking or stopping smoking and not drinking or stopping drinking excessive amounts of alcohol can lower your risk of developing breast cancer. For women with babies, breast-feeding for longer than six months is not only healthy for the mother but also for the baby. Menopausal or post-menopausal women taking hormone replacement therapy should arrange regular breast cancer screening.
While CT scans and X-rays can detect a range of illnesses, they emit large amounts of radiation and can cause damage to cells. This damage can lead to cell mutations and cancer. MRI scans do not use radiation but electromagnetic energy and are therefore much safer; however, they are not as cost-efficient as radiation-emitting machines and hospitals tend to limit their use. A less expensive option is ultrasound that uses soundwaves to produce an image. Arranging your own MRI scan at a private hospital can be a good idea.
It is also important to mention that people who regularly travel on long-haul (high altitude) flights can be exposed to higher radiation levels and should opt for the MRI scan (or ultrasound) rather than a CT scan or X-ray whenever possible.
Learning how to check your own breasts for lumps is also important. Your general practitioner or gynaecologist can show you how to do this. Be aware of skin changes and itchy or warm sensations in and around the breasts and make an appointment with your general practitioner, oncologist or gynaecologist if you do notice anything unusual.
How is breast cancer diagnosed?
Most breast cancers start as very small groups of mutated cells. Those with heavier breasts or less sensitive fingertips (such as diabetics) may find it hard to detect tiny growths. This is why screening is so important.
Breast screening involves a mammogram. This is an X-ray of both breasts and is not a comfortable experience as the breast tissue must be flattened between plastic plates in order to get the best image. A mammogram is the first step to breast cancer detection. If the radiologist notices something unusual on the X-ray or if the breasts are particularly heavy and the X-ray image is difficult to view, he or she will request an ultrasound.
If the radiologist is still unsure of a diagnosis, the next step is a breast MRI. An MRI provides much more detailed images of the breast tissue and does not involve radiation. It is important to mention that many lumps and bumps in the breasts are benign, such as cysts. So if a lump is detected, this does not mean you have breast cancer. In fact, up to 80% of women who are sent for biopsy do not have breast cancer.
To see whether a group of unusual cells is cancerous or not, the next step is a breast biopsy. There are two ways in which biopsies are carried out on breast tissue – core-needle aspiration and surgery. The first of these involves inserting hollow needles into certain areas of one or both breasts using ultrasound and is performed under a local anaesthetic. Occasionally, a marker is placed into suspicious tissue so that the surgeon can locate the area if he or she needs to operate. The second biopsy type is a surgical procedure but is usually performed with a local anaesthetic and sedation. A small incision is necessary to access the breast tissue. Again, the doctor may place a marker to help the surgeon locate the area should you need an operation at a slightly later stage.
If your biopsy results are positive for breast cancer, you will be sent for a PET scan and possibly a bone density scan. As the breast is a gland, a Dotatate PET scan may be advised. This scan requires some medications to be stopped up to two months beforehand – your GP or our specialist physicians will be able to tell you if this applies to you. For this test, you will be administered a small quantity of radioactive tracer via an intravenous catheter then wait for 45 minutes until this tracer reaches the site of potential cancerous cells. The scan itself takes up to 30 minutes and is carried out in the same way as a regular PET scan.
A biopsy is important when determining breast cancer treatment. The pathologist can see if the tissue contains cancer cells and, if so, whether these may respond to hormonal or HER2 therapy. They also tell the surgeon how much tissue he or she should remove. When your biopsy tissue samples are sent for testing, your oncologist will also order specific tests that can determine which treatment pathways best suit your cancer’s specific cell type. For example, triple positive breast cancer (determined by an immunohistochemistry (IHC) test on biopsy samples) can be treated with supplementary HER2 targeted therapies and hormone therapies in combination with a standard breast cancer treatment plan. This ability to match treatment to individuals instead of treatment to a disease as a whole is called personalised medicine. Personalised medicine is making waves throughout the medical sector and especially in the field of cancer therapy. Because new studies are continuously providing newer, better ways to further personalise treatment plans, Remedazo insists its partner oncologists, haematologists and pathologists are well-read in current research and new diagnostic, prognostic and treatment techniques.
In addition to hormone and HER2 receptor tests, your oncologist will also order prognostic tests such as the KI-67 biomarker test (or mitotic index test) that, in early-stage hormone-responsive breast cancer types, can show how rapidly your cancer is growing. The Ki-67 measures the presence of proteins that are released only during the multiplication phase of cells. If your diagnostic report shows a Ki-67 result of 2%, only 2 in every 100 cells are dividing. Results of over 20% indicates rapid growth and may mean that your oncologist recommends high-dose chemotherapy in combination with other treatment methods.
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