Introduction to Diagnosis, Breast Cancer Types, Staging and Grading

When first diagnosed, it is important to remember that breast cancer is not just one type of cancer. No two types are the same and no two women are the same.  You cannot compare your diagnosis to someone else's prognosis. Just because two women have the same disease does not mean that their outcome will be the same.

It is vital that you learn as much as you can about your particular cancer. The more you know, the better patient you are because you become a partner in your health care decisions with your doctor. Don't be afraid to ask questions, and don't leave until you are satisfied with the answers you get.

Here you will find the different types of breast cancer broken down for your information.

DCIS is sometimes called a pre-cancer.  It can often be cured with a mastectomy alone. Some women have DCIS in only one quadrant of the breast, “multi-focal”, and can have a lumpectomy and radiation. Others have it in more than one quadrant, “multi-centric” and then the only choice is mastectomy.

When a pathologist examines it later, he will be able to measure how fast it grew and how aggressive it was by how many of the cells are dead, (necrosis), how many new cells are created (mitosis) and what role the DNA played in this cycle. From this information you and your doctor can decide on what treatment plan is best for you.

Lobular Carcinoma In Situ (LCIS) is cancer that is confined to the milk lobule. The cells could sit dormant for a woman’s lifetime, because of this it also referred to as a “neoplasm” or pre- malignancy.

Invasive lobular is hard to detect because rather than forming a lump it grows in what has been described as sheets or leaves. If you imagine a branch of a tree and  the leaves filling out and growing, that is essentially how lobular cancer appears when it is spreading.

Tremendous strides have been made and there has been a dramatic change in the prognosis of IBC.

Inflammatory breast cancer is a very aggressive form of breast cancer. It presents itself with swelling, a feeling of heat inside the skin, a red tinge to the breast area and the breast sometimes swells up too. In some cases dark red or purple stripes may appear across the chest.  The skin may pucker inwards like the skin of an orange.  At first glance a doctor would view a swollen, hot breast with a rash and declare mastitis, which is a breast infection. Antibiotics are given and nothing helps. Sometimes it may take several visits to the doctor or even a change in doctors before the possibility of IBC is investigated.

Paget’s Disease

Paget’s disease is sometimes cancerous, but not always. When it is cancer, it is a type of in situ cancer that can begin in the ducts of the nipple. It grows close to the skin or the nipple and then can appear like IBC does with the swelling, heat and the orange peel skin. There may also be an itchy rash and a bloody discharge from the nipple. The nipple will also become inverted.

Medullary cancer is a cancer with the best prognosis of all. It is clearly identifiable and not as aggressive as the other breast cancers. Only a very small percent of women are diagnosed with Medullary cancer. However, women who carry the breast cancer gene mutation, BRCA 1, have a greater chance of developing Medullary cancer.

Generally, the prognosis for patients with medullary carcinoma is better than for women with other types of invasive ductal or lobular carcinoma.

The Specifics that Doctors  Look For in your Tumor

This means that the tumor is fueled by the estrogen and progesterone in your body. If your tumor is not fueled by estrogen or progesterone, then it is called Estrogen/Progesterone Negative. This type of cancer is impervious to estrogen and does not rely on it for it to grow.

If you are diagnosed with an Estrogen/Progesterone negative cancer, these drugs are useless to you because your tumor does not rely on estrogen to grow so there is no need to shut down the naturally occurring hormones in your body.

Twenty-five to thirty percent of breast cancer tumors carry the Her2/nue oncogene. This protein over-expresses in a cancer cell making it more aggressive and promoting cancer growth. If you test positive for this gene it will appear on your path report as Her2+. There have been tremendous breakthroughs in the treatment of Her2+ cancers. Herceptin, (Trastuzumab) and Tykerb, (Lapatinib) are now being administered after chemotherapy and have been shown greatly reduce the Her2 protein which is prolonging the lives of women who have been diagnosed Her2 +.

How Far Did it Go?

During surgery your doctor will also look beyond the breast to see if your cancer has spread.

Lymph nodes are small glands that filter the protein rich lymphatic fluid through your body . If something that is not supposed to be there enters them, the lymph nodes trap it and hold it so it does not spread throughout your body. They filter the good lymphatic fluid and clear it of anything that shouldn’t be there.

The axillary lymph nodes, where your breast filters to, are located under your arm in a little bundle of fat. That bundle can hold from 5 to sometimes over 40 nodes. If you were to get the traditional surgery of complete lymph node dissection, the surgeon would remove that entire bundle. It would then be sent to the path lab for the cytologist to sort out.

Cancer’s Basic Stages

When all is said and done, and your surgery is over, all the information is gathered and your cancer is staged. This is how they take all this information and stage your cancer:

When a surgeon operates on you he will be able to identify if your cancer is Invasive or InSitu. An invasive or infiltrating cancer is a tumor that has grown out of or broken through the milk duct or the milk lobule where the cancer originated.

A doctor then looks at the size. You are tested to see if it has spread to the lymphatic system. That is done by examining your lymph nodes.

Next, the receptors of your cancer are measured- do they respond to estrogen or progesterone or not? Do you have the Her-2/nue oncogene over expressing in your tumor cell?

And finally, how does your tumor look? Is it easy and clear to see the living cells from the dead ones? Are there more dead cells than living ones? If there are then it is more aggressive, if not, then it is slower growing.

They take all this information and put it into a formula and come up with a staging system. Here is the basic staging system according to the American Cancer Society:

Stage 0: InSitu cancer

Stage1: Tumor is under 2 centimeters and there is no lymph node involvement

Stage2: Tumor is larger than 2 cm but smaller than 5 cm and may or may not have spread to the lymph nodes under the arm of the affected side. No other tissue is affected and the lymph nodes are not attached to one another.

Stage3A: Tumor is larger than 5 cm and lymph nodes of affected side are positive and are attached to one another.

Stage 3B:  Any tumor that has spread to the chest wall, skin, and lymph nodes of the armpit, breast, and chest.

Stage 4:  The tumor can be of any size but the cancer has spread to another part of the body, bones, lungs and other lymph nodes.

Next they take this stage and add on the prognosticator factors that can be found in the genes, through hormone receptors, and whether the tumor was aggressive or not.

Your Pathologist will also GRADE your tumor.

BLOOM RICHARDSON SCALE

This is an aggressiveness grading system or better known as how much horse power your tumor has. This tells the pathologist just how ambitious your tumor really was. It looks at the following three things:

1. If the cell has formed tubular features
(the more tubular features the less aggressive your tumor is)

2. The “nuclear grade” meaning the activity of the DNA
(how quickly is the dna of the good cells are being mutated)

3. How many cells divide at once, also known as the mitotic rate, which means the rate at which new cells were created.

The lowest you can score on this scale is 3 (grade 1). That is the best score because that means you have a very slow growing, non- aggressive cancer. The highest is 9 (grade 3) meaning your cancer cells are rapidly dividing and very aggressive.

GRADING SYSTEM

Grade 1
Means your B/R score was between 3-5

Grade 2
Means your B/R score was between 6-7

Grade 3
Means your B/R score was between 8-9

Remember! Don't confuse your GRADE with your STAGE!

You can score a Grade 3 but still have a Stage 1 cancer. For example, if you have a highly aggressive cancer that scores high on the Bloom/Richardson scale but the tumor itself is still small and has no lymph node involvement, you will have a stage one cancer.