Breast cancer

Breast cancer staging

TNM staging is a system used to calculate how advanced a cancer is, and ranges from stage 0 to stage 4.

The TNM system evaluates anatomic factors which can help determine the likely outcome of the disease ( prognosis) and select an appropriate treatment plan. These factors are the size of the tumour (T), the number and location of cancerous lymph nodes (N), and whether the cancer has metastasized or spread to other tissue or organs (M).

In January 2018 the system was revised to take into account additional tumour biology factors which can affect outcome, such as tumour grade, HER2 over-expression, hormone receptor expression and the results of genomic tests ( if used).

Using this updated system, the extra information provided by these biologic factors may modify the stage which would have been assigned by using anatomic factors alone. For instance a small high grade ( grade 3) tumour which is hormone receptor positive and HER2 negative would be assessed as one stage higher than previously. Similarly a tumour which is triple negative, regardless of grade would be determined to be one stage higher.

Results from predictive genomic panels such as Oncotype Dx may in some cases downgrade tumours by one stage compared to the old system using TNM alone if the results show a low score for risk of recurrence.

The TNM scale ranges from stage 0 to stage IV. A higher stage indicates more advanced cancer. The chart below gives a summary of TNM staging.

Stage should not be confused with Grade (1, 2 or 3) which reflects what the cancer cells look like under a microscope, how different they look from normal healthy breast cells and how actively they are dividing and growing.

T refers to tumour size

Size is measured under a microscope. It is important because the smaller the tumour, the less likely it is to have spread beyond the breast and the better the chance for successful treatment. Small tumours are generally classified as two centimetres (20mm) or less.

N refers to lymph node status

Lymph node status is determined by a pathologist who examines any nodes under a microscope after they have been removed from the armpit (axilla) during surgery. If any nodes contain cancer cells, they are called positive nodes.

M refers to metastasis

Metastasis is the spread of cancer to other areas of the body, otherwise known as distant spread. Some breast cancer cells have the ability to invade lymphatic and/or blood vessels where they can circulate to distant organs and tissues e.g. bones, liver, lungs and brain. Imaging such as CT scans and bone scans can be performed if the tumour is high risk and/or metastases are suspected.

The TNM scale

Stage (T) Tumour Size (N) Axillary Lymph Nodes (M) Metastasis
0 (is) Tiny cluster of cancer cells in a breast duct (in situ) No spread None
I Up to 2cm No spread None
II Smaller than 2cm Has spread to the axillary lymph nodes None
Between 2cm & 5cm May or may not have spread to the axillary lymph nodes None
Larger than 5cm No spread None
III Any size Has spread to multiple axillary lymph nodes so that the nodes become attached to each other None
Larger than 5cm Has spread to axillary lymph nodes None

Any size but cells have spread to skin or chest wall May or may not have spread to the axillary lymph nodes None
Any size Has spread to lymph nodes along breastbone and above/below collarbone None
IV Any size May or may not have spread to the axillary lymph nodes Has spread to other organs of the body or the skin and lymph nodes above the collarbone

AJCC 8th Edition Staging Revisions

Examples of Revisions to Breast Cancer Staging Using Biomarkers and Oncotype DX

  1. Abbreviations: −, negative; O+, positive; ER, estrogen receptor; G, grade; HER2, human epidermal growth factor receptor 2; M, metastasis classification; N, lymph node classification; PR, progesterone receptor; T, tumor classification.
1 0 0 1 IA IIA
1 0 0 3 + IA IIA
3 1-2 0 1 + + + IIIA IB
Oncotype DX recurrence score < 11 for ER-positive tumors
2 0 0 Any + Any IIA IB
1-2 1 0 Any + Any IIA/IIB IB
0-2 2 0 1-2 + + + IIIA IB

- American Joint Committee on Cancer 2017 (8th edition)