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Staging and Grading Breast Cancer

Knowing the stageStage:
A way of classifying breast cancer that describes how far a cancer has spread. It identifies whether breast cancer is at an early, locally advanced or metastatic stage. The stage of breast cancer can sometimes be represented as a number (e.g. between 0 and 4).
, gradeGrade:
A way of classifying cancer that describes how aggressive the cancer is likely to be (i.e., how fast it will grow and spread).
and receptorReceptor:
Cells have many different proteins on their surface called receptors. Her-2 is one kind of receptor. In normal cells, HER-2 receptors are thought to be involved in cell growth and reproduction. In some breast cancers, there are too many HER-2 receptors and they speed up cancer cell growth.
status of your breast cancer gives you and your health care team important information. It helps to determine your prognosisPrognosis:
A prediction of the likely outcome and chance of recovery from a disease. A doctor makes a prognosis based on statistics and other information gathered from studies of a large number of people with the same disease. Prognosis affected by the type and severity of the disease, treatments available and other factors such as the age and overall general health of the person affected.
(the likely outcome of your condition and chance of recovery) and allows your health care team to advise you on the best treatment options for you. Your health care team will draw on scientific evidence and the experience gained from treating many other patients with breast cancer.

Many of the tests that are used to diagnose breast cancer are also used to determine the stage, grade and receptor status. This includes looking at the results of biopsiesBiopsy:
A procedure in which tissue samples are removed from the body for examination under a microscope to determine if cancer or other abnormal cells are present.
and tissue removed during surgery, and in some cases the results of imaging tests like ultrasoundUltrasound:
An imaging technique that uses sound waves to take a picture of structures in the body, such as the breast.
, X-ray, bone scansBone scan:
A test that uses small amounts of radioactive material to create images of the bones. It is an important tool for detecting cancer that has spread (metastasized) to the bone.
or CT scansComputed Tomography (CT) scan:
An imaging technique that takes a series of x-rays from many different angles and combines them to create a detailed 3-dimensional image of the bones and tissues in your body, such as the breast.

Stages of breast cancer

When breast cancer has been diagnosed, it is important to determine the stage of the cancer. Staging describes how far a cancer has spread and helps to identify whether breast cancer is at an early, locally advancedLocally advanced (breast cancer):
Breast cancer that is greater than 5cm in diameter or has spread to multiple lymph nodes and/or to other tissues in the area, but has not spread to distant sites in the body.
or metastaticMetastatic (metastases):
The spread of cancer from its original (primary) location to another part of the body. A tumour that is formed by cancer cells that have spread to another part of the body is called a “metastatic tumour” or a “metastasis.”
stage.

One of the most common staging systems is the TNM system, which stands for Tumour, Nodes and Metastases. This system considers the size of the tumourTumour:
An abnormal mass of tissue that occurs when cells divide more than they should or do not die when they should. Tumours may be benign (not cancer) or malignant (cancer). A tumour is also called a neoplasm.
, the number of lymph nodesLymph nodes:
Small structures that filter lymph fluid for harmful substances. They contain immune cells that can help fight infection by attacking and destroying germs. Cancer can travel through the lymphatic system spread to the lymph nodes.
that are affected, if any, and the other parts of the body that the cancer has spread (metastasized) to, if any.

These three factors are combined to give an overall stage between 0 and IV (0 to 4), which is why you will hear people talk about their “stage” of cancer. Staging helps identify whether breast cancer is at an early or advanced stage, with a lower number indicating an earlier cancer and a higher number indicating a more advanced cancer. For both staging and grading, lower values are associated with a more favourable outcome.

Stage 0: The cancer has not spread and is at an early stage

Stages I - III: The cancer has grown larger or has spread into nearby tissues. It may have also spread to the lymph nodes. The higher the number, the more the cancer has spread and the more advanced it is

Stage IV: The cancer has spread to other parts of the body (metastasized)

Diagnosis-Staging-and-grading.jpg*Note: For people diagnosed with stage I breast cancer, a small number of cancer cellsCell:
The basic structural and functional unit of all organisms.
may be present in the lymph nodes.

Metastatic breast cancer

When breast cancer spreads, or metastasizes, the most common sites include the bones, liver, brain and lungs. Once it has spread outside of the breast and lymph nodes to other parts of the body, breast cancer is no longer considered curable. However, it can still be treated and many people live with metastatic breast cancer for a long time. There are resources and support services available for people living with metastatic breast cancer.

Grading breast cancer

Breast cancer is also classified by grade. Grading takes into account several features of the cancer and indicates how aggressive the cancer is likely to be (how fast it will grow and spread). The grade is determined by examining the appearance and behaviour of cancer cells under a microscope. The more cancer cells look and behave like normal cells, the slower the cancer is likely to grow and spread, and the lower the grade assigned.

How similar the cancer cells are to normal cells is described by how “differentiated” they are. A well-differentiated tumour acts and looks similar to normal cells, and will grow and spread more slowly than poorly differentiated or undifferentated tumours. Undifferentiated cancer cells do not look or act like the cells in the tissue they came from – they lack the basic structures and functions of the normal cell. Undifferentiated cancers often grow and spread quickly.

The grading system used depends on the type of cancer. For breast cancer, the Nottingham modification of the Bloom-Richardson scale is most commonly used. This grading scale looks at 3 different cell features and gives each of them a score from 1-3. The scores from each of these features is added up to give a total score, which indicates the tumour grade.

Bloom-Richardson Grade – Nottingham modification

Grade  ​Combined Score ​ Description
​I 3-5 Low-grade (well-differentiated) tumours that do not appear to be growing quickly and are less likely to spread
​II 6-7 Intermediate-grade (moderately differentiated) tumours that have features between grade 1 and 3
​III 8-9 High-grade (poorly differentiated or undifferentiated) tumours that tend to grow faster and are more likely to spread
 Source: Canadian Cancer Society. Grades of breast cancer.

Receptor status

Breast Cancer Receptor2.jpgIn addition to staging and grading information, your oncologistOncologist:
A doctor or surgeon who specializes in treating cancer. A medical oncologist specializes in drug therapy (chemotherapy) for cancer. A radiation oncologist specializes in treating cancer with radiation.
will consider what is known as the “receptor status” of the cells. This information is determined by a pathologistPathologist:
A doctor who specializes in the diagnosis of disease by examining cells, body fluids and tissue.
, who will test tissue samples from your tumour collected during a biopsy. Some breast cancer cells have receptors into which the female hormoneHormone:
A natural substance released into the body by the endocrine glands, such as the thyroid, adrenal gland or ovaries.
molecules (estrogenEstrogen:
A female sex hormone that is produced mainly in the ovaries. A woman’s levels of estrogen fluctuate throughout her life. Estrogen has been linked to the development of breast cancer and may promote the growth of cancer cells.
and progesteroneProgesterone:
A female sex hormone released by the ovaries during the woman’s menstrual cycle to prepare the uterus for pregnancy and stimulate milk production in the breast. It is also one of the synthetic hormones used in hormone replacement therapy.
) fit like a lock and key. These are known as hormone receptor positive (HR+) cancers. If these receptors are present, hormones will encourage the cancer to grow. It also means they are more likely to respond to hormone therapyHormone therapy:
A treatment method for breast cancer that uses medication to block the production of the hormone estrogen, or the way that it works in the body.
for treatment. HR+ cancers can be estrogen receptor positive (ER+), progesterone receptor positive (PR+), or both.

Some tumours also produce too much of a receptor called HER-2-neuHER-2-neu:
Cells have many different proteins on their surface called receptors. HER-2 is a type of naturally occurring receptor. In normal cells, HER-2 receptors are thought to be involved in cell growth and reproduction. In some breast cancers, there are too many HER-2 receptors and they speed up cancer cell growth. HER-2 therapy is used to treat some breast cancers by targeting receptors that stimulate breast cancer growth.
. When this happens, the HER-2 receptor tells the cancer cells to grow faster. These are known as HER-2 positive tumours. HER-2 status testing is done on breast tissue samples taken from a biopsy.

Knowing the stage, grade, receptor status and number of HER-2 receptors for your breast cancer will allow your health care team to decide with you the best treatment options for your condition.

Prognostic tests

For women diagnosed with early stage HR+ breast cancer, tests may be done that can help predict the likelihood that breast cancer will return in the future. These tests are usually done when you are first diagnosed, using the tissue sample that was taken during biopsy or surgery. Having this information can help your health care team plan your treatment. Examples of these tests include OncotypeDX and MammaPrint. In some provinces and territories, this test may be covered by your health care plan.

 

Sources:

Canadian Breast Cancer Foundation. (2008). Guiding women though a breast cancer diagnosis. A supportive and personal approach.

Canadian Cancer Society.  Grades of Breast Cancer.  Accessed January 3, 2014.

Canadian Cancer Society. HER2 status testing.  Accessed January 3, 2014.

Canadian Cancer Society. Hormone receptor status testing. Accessed January 3, 2014.

Canadian Cancer Society. Prognosis and survival for breast cancer.  Accessed January 3, 2014.

HealthLinkBC (BC Government). Cancer Staging and Grading.  Accessed January 3, 2014.

National Cancer Institute. Tumor Grade.  Accessed January 3, 2014.