Breast Cancer Staging Symposium on Best Practice in Recording Cancer Stage Royal College of Pathologists 10 June 2011 Dr Gill Lawrence, Director Tel: 0121 415 8129 Fax: 0121 414 7712 Email: gill.lawrence@wmciu.nhs.uk
Why do we need to know breast cancer stage? To predict survival/prognosis To determine appropriate treatment To target health promotion and health awareness activities to promote earlier diagnosis in communities with poorer outcomes
Breast cancer survival Breast cancer has relatively good prognosis Relative survival at 10 years for all women diagnosed with invasive breast cancer in England in1992/93 is 67% Relative survival at 15 years for invasive breast cancers diagnosed by screening in the UK in 1992/93 is 83% This difference reflects the earlier stage at diagnosis of cancers detected by the NHS Breast Screening Programme
<30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 Proportion of cancers with surgery 90+ How do we stage breast cancers? The majority of breast cancer patients have surgery In 2007 82% of the women diagnosed with breast cancer in the UK had surgery recorded Symptomatic breast cancer 75% Screen-detected breast cancer 98% better prognostic factors younger age fewer co-morbid conditions Pathological stage is available for the majority of breast cancer patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Screen-detected Symptomatic all breast cancers Age at diagnosis
What determines breast cancer stage? Tumour characteristic Tumour behaviour Invasive tumour size Invasive tumour grade Nodal status Distant metastatic spread Clinical/ Pre-treatment Cytology or more commonly core biopsy Imaging - generally x- ray mammography MRI for dense breasts Determined from core biopsy Ultrasound imaging with FNA, core biopsy if abnormal, SLNB Pathological/ Post surgery Non-invasive, micro-invasive and invasive behaviour Microscopic - from excision report Microscopic - from excision report Microscopic - from excision report Comments/Issues Cytology identifies presence of malignant cells, not if an invasive or non-invasive cancer is present Non-invasive component also influences surgical treatment Neo-adjuvant therapy to shrink tumour Core and excision sample grade may differ. In UK Bloom and Richardson grade used rather than UICC grade pathology levels and micromets, neo-adjuvant therapy, fixed nodes Clinical assessment guidelines advise against use of imaging to look for distant metastatic spread for early stage breast cancers Mx can be taken to be M0 for many invasive breast cancers
Nodes Grade Size Relative survival rate How do these factors affect survival? Having surgery improves survival Invasive and micro-invasive breast cancers diagnosed in women in 2007 1-year relative survival Unknow n >50mm >35-50mm >20-35mm 15-20mm <15mm Unknow n Grade III Grade II Grade I Unknow n Negative Positive 0 10 20 30 40 50 60 70 80 90 100 15 year relative survival (%) 100 80 60 40 20 0 Aged <40 All cases Surgically treated only No surgery 40-49 50-59 60-69 70-79 80+ Age at diagnosis Tumour size, grade and nodal status Screen-detected invasive cancers diagnosed in women in 1992/93 15-year relative survival
How do we determine breast cancer stage? TNM Stage Behaviour Tumour (size and extent of spread within the breast) Nodes (spread to regional lymph nodes, fixation) Metastases (spread to distant nodes and organs) Nottingham Prognostic Index (NPI) Invasive tumour size Invasive tumour grade Nodal involvement (axillary nodes + intra-mammary nodes) SEER Summary Stage In situ Localised Regional Distant
Can we map between staging systems? TNM SEER NPI Tis In situ - Overall Stage I - N0 Localised Excellent Prognostic Group node -ve Overall Stage II - N0 Overall Stage III - N0 Localised Localised Good Prognostic Group Moderate Prognostic Group 1 Moderate Prognostic Group 2 Overall Stage II - N+ve Regional (depending on tumour size and number of nodes involved) Overall Stage III - N+ve Regional Poor Prognostic Group Overall Stage IV - M+ve Distant - Can t allocate some tumours to TNM Stage II or Stage III as nodal fixation is unknown
5 year relative survival (%) And finally some positive news.. 5-year relative survival for women diagnosed with screen-detected invasive and micro-invasive breast cancers in 1992/93 and 2002/03 100 90 80 70 60 50 40 30 20 10 Improved survival for poor prognostic cancers due to better adjuvant therapy 0 EPG GPG MPG1 MPG2 PPG 1992/93 2002/03 Nottingham Prognostic Index Group