Treatment of Breast Cancer by Stages

  • Medical Author:
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

  • Medical Editor: Jerry R. Balentine, DO, FACEP
    Jerry R. Balentine, DO, FACEP

    Jerry R. Balentine, DO, FACEP

    Dr. Balentine received his undergraduate degree from McDaniel College in Westminster, Maryland. He attended medical school at the Philadelphia College of Osteopathic Medicine graduating in1983. He completed his internship at St. Joseph's Hospital in Philadelphia and his Emergency Medicine residency at Lincoln Medical and Mental Health Center in the Bronx, where he served as chief resident.

How is breast cancer staging determined?

Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival.

To determine if the cancer has spread, several different imaging techniques can be used.

What is breast cancer staging?

The stage of a cancer refers to the extent to which it has spread within the body at the time of diagnosis. Staging of cancers is typically done using a variety of tests and imaging studies to look for the extent of the cancer. To accurately determine the stage of a tumor, doctors look at the size of the tumor, the degree to which it has spread to nearby tissues, and the degree to which it has spread via the bloodstream to other organs or via the lymphatic vessels to the lymph nodes.

Breast cancer stages are divided into four broad groups: I, II, III, and IV. Within each of these four groups are several different subgroups. Ductal carcinoma in situ (DCIS) is a regarded as a very early form of breast cancer in which the abnormal cells have not begun to invade outside of the breast ducts; DCIS is sometimes referred to as stage 0 cancer. This article will focus on the treatment of invasive breast cancer in stages I-IV.

What is the treatment for stage I breast cancer?

Stage I breast cancers are small and have not spread to the lymph nodes or have spread to the lymph nodes only in a tiny area.

Surgery is the standard treatment for early stage breast cancers. Both breast-conserving surgery (BCS; also referred to as lumpectomy or partial mastectomy) or mastectomy may be performed, depending upon many factors, including both location of the tumor and patient preference. The lymph nodes will also be evaluated to make certain there is no spread to these areas. This can be done by either a sentinel lymph node biopsy (looking at the lymph node most likely to be the site of tumor spread) or an axillary lymph node dissection. Breast reconstruction surgery can be done either at the same time as the cancer surgery or later on.

When BCS is performed, it is most commonly followed by radiation therapy to help reduce the risk of the cancer coming back (recurring). In women over 70 years of age who have small tumors that have not spread to the lymph nodes, radiation therapy may not always be given if the tumor has been shown to express hormone receptors and hormone therapy is given.

Any additional therapy depends upon the characteristics of the tumor. If the tumor expresses hormone receptors (estrogen, progesterone), it is said to be hormone-sensitive or hormone receptor-positive. This means that hormones stimulate growth of the cancer cells, and hormone therapy is recommended. The goal of hormone therapy is to block the body's ability to make hormones or to interfere with the activity of hormones.

Two different kinds of hormone therapy may be given. Tamoxifen (Nolvadex) is a commonly used drug of the selective estrogen receptor modulator (SERM) class. These drugs bind to estrogen receptors, preventing estrogen from binding. Tamoxifen is typically prescribed for premenopausal women (and men) who have estrogen receptor-positive breast cancer. Tamoxifen therapy is given for five to 10 years. Another drug class used for breast cancer hormone therapy is the aromatase inhibitors (AI). Women who are postmenopausal will usually receive adjuvant hormone therapy with an aromatase inhibitor, like anastrozole (Arimidex), letrozole (Femara), or exemestane (Aromasin). Women who become postmenopausal during tamoxifen treatment may be switched to an aromatase inhibitor. Because women may stop having periods on tamoxifen, blood tests to measure hormone levels are often needed to determine whether menopause has occurred. Another option for premenopausal women, instead of tamoxifen, is taking a medication to suppress activity of the ovaries along with an AI. Bisphosphonates are a drug class that can help reduce bone loss and fractures as well as improve survival in women taking AIs for breast cancer.

Hormone therapy is one type of adjuvant therapy (therapy that is given for the cancer after surgery). Chemotherapy is another type of adjuvant therapy. For early stage breast cancers, including stage I tumors, chemotherapy is sometimes recommended. Chemotherapy is usually recommended if the tumor is hormone receptor-negative or is HER2-positive (see below). Chemotherapy may also be recommended for an estrogen-receptor-positive tumor is the tumor is large or has an unfavorable result on a genomic profiling assay such as the Oncotype DX Breast Cancer Assay. Chemotherapy is usually given for a period of three to six months depending upon the exact regimen selected.

Tumors that overexpress the HER2 (human epidermal growth factor receptor 2) receptor are generally treated with adjuvant HER2-targeted therapy. HER2 is a normal protein that helps normal breast cells grow and divide. However, in certain breast cancers, there are too many copies of the HER2 gene, leading to overexpression of the protein and uncontrolled cell growth. These are called HER2-positive cancers. Trastuzumab (Herceptin) is an example of an anti-HER2 drug that binds to the HER2 receptors and blocks their reception of growth signals.

Medically Reviewed by a Doctor on 8/21/2015

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