Breast cancer natural history

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2] Mirdula Sharma, MBBS [3]

Overview

If left untreated, 22% of patients with breast cancer may regress. Common complications of breast cancer include metastasis. Prognosis is generally good with treatment.

Natural History

There is a theory that up to 22% of small (radiographically detected) breast tumors regress, based on an analysis in a large population.^[1] The study is supported by NCI's SEER data.^[2]
The natural history of breast cancer is extremely variable ranging from indolent cancers to aggressive cancers that can metastasize with fatal consequences.^[3]

Prognosis

The prognosis and treatment options depend on the following:

The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body)
The type of breast cancer
Estrogen receptor and progesterone receptor levels in the tumor tissue
Human epidermal growth factor type 2 receptor (HER2/neu) levels in the tumor tissue
Whether the tumor tissue is triple negative (cells that do not have estrogen receptors, progesterone receptors, or high levels of HER2/neu)
How fast the tumor is growing
How likely the tumor is to recur (come back)
A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods)
Whether the cancer has just been diagnosed or has recurred (come back)

Nottingham Prognostic Index

The Nottingham prognostic index (NPI) is used to determine prognosis following surgery for breast cancer. Its value is calculated using three pathological criteria: the size of the lesion; the number of involved lymph nodes; and the grade of the tumor.^[4]

Calculation

The index is calculated using the formula:

NPI = [0.2 x S] + N + G

Where:

S is the size of the index lesion in centimetres
N is the node status: 0 nodes = 1, 1-4 nodes = 2, >4 nodes = 3
G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3

Interpretation

Score	5-year survival
2.0 to 2.4	93%
2.5 to 3.4	85%
3.5 to 5.4	70%
> 5.4	50%

Estimated five year survival rates:^[5]

stage I: ~87%

stage II: ~75%

stage III: ~46%

stage IV: ~13%

AJCC clinical prognosis categorization

The 8th revision of AJCC staging system for breast cancer has been extensively modified.
Rather than classic TNM system, other characteristics of tumors such as pathologic grade, the presence of ER, PR, hormone receptors as well as presence of certain genetic mutations such as HER2 has been integrated into the latest revision.
Patients has been assigned to clinical prognosis stages with respect to the above-mentioned criteria.

Approach to determine the clinical prognostic stage group of the patients according to the AJCC staging recommendations for breast cancer (8th edition)

TNM	Histopathologic Grade	HER2	ER	PR	Clinical prognostic stage group
Tis N0 M0	Any	Any	Any	Any	0
T1* N0 M0 T0 N1mi M0 T1*N1mi M0	G1	Any	Any	Any	IA
					IA
					IA
					IA
					IA
					IA
					IA
			-	-	IB
		-
T1* N0 M0 T0 N1mi M0 T1* N1mi M0	G2	Any	Any	Any	IA
					IA
					IA
					IA
					IA
					IA
					IA
				-	IB
		-	-
T1* N0 M0 T0 N1mi M0 T1* N1mi M0	G3	+	Any	Any	IA
					IA
					IA
					IA
		-	+	+	IA
				-	IB
			-	+	IB
				-	IB
T0 N1¶ M0 T1* N1¶ M0 T2 N0 M0	G1	+	+	+	IB
				-	IIA
			-	+	IIA
				-	IIA
		-	+	+	IB
				-	IIA
			-	+	IIA
				-	IIA
T0 N1¶ M0 T1* N1¶ M0 T2 N0 M0	G2	+	+	+	IB
				-	IIA
			-	+	IIA
				-	IIA
		-	+	+	IB
				-	IIA
			-	+	IIA
				-	IIB
T0 N1¶ M0 T1* N1¶ M0 T2 N0 M0	G3	+	+	+	IB
				-	IIA
			-	+	IIA
				-	IIA
		-	+	+	IIA
				-	IIB
			-	+	IIB
				-	IIB
T2 N1Δ M0 T3 N0 M0	G1	+	+	+	IB
				-	IIA
			-	+	IIA
				-	IIB
		-	+	+	IIA
				-	IIB
			-	+	IIB
				-	IIB
T2 N1Δ M0 T3 N0 M0	G2	+	+	+	IB
				-	IIA
			-	+	IIA
				-	IIB
		-	+	+	IIA
				-	IIB
			-	+	IIB
				-	IIIB
T2 N1Δ M0 T3 N0 M0	G3	+	+	+	IB
				-	IIB
			-	+	IIB
				-	IIB
		-	+	+	IIB
				-	IIIA
			-	+	IIIA
				-	IIIB
T0 N2 M0 T1* N2 M0 T2 N2 M0 T3 N1Δ M0 T3 N2 M0	G1	+	+	+	IIA
				-	IIIA
			-	+	IIIA
				-	IIIA
		-	+	+	IIA
				-	IIIA
			-	+	IIIA
				-	IIIB
T0 N2 M0 T1* N2 M0 T2 N2 M0 T3 N1Δ M0 T3 N2 M0	G2	+	+	+	IIA
				-	IIIA
			-	+	IIIA
				-	IIIA
		-	+	+	IIA
				-	IIIA
			-	+	IIIA
				-	IIIB
T0 N2 M0 T1* N2 M0 T2 N2 M0 T3 N1Δ M0 T3 N2 M0	G3	+	+	+	IIB
				-	IIIA
			-	+	IIIA
				-	IIIA
		-	+	+	IIIA
				-	IIIB
			-	+	IIIB
				-	IIIC
T4 N0 M0 T4 N1Δ M0 T4 N2 M0 Any T N3 M0	G1	+	+	+	IIIA
				-	IIIB
			-	+	IIIB
				-	IIIB
		-	+	+	IIIB
				-	IIIB
			-	+	IIIB
				-	IIIC
T4 N0 M0 T4 N1Δ M0 T4 N2 M0 Any T N3 M0	G2	+	+	+	IIIA
				-	IIIB
			-	+	IIIB
				-	IIIB
		-	+	+	IIIB
				-	IIIB
			-	+	IIIB
				-	IIIC
T4 N0 M0 T4 N1Δ M0 T4 N2 M0 Any T N3 M0	G3	+	+	+	IIIB
				-	IIIB
			-	+	IIIB
				-	IIIB
		-	+	+	IIIB
				-	IIIC
			-	+	IIIC
				-	IIIC
Any T Any N M1	Any	Any	Any	Any	IV

References

↑ Zahl PH, Maehlen J, Welch HG (2008). "The natural history of invasive breast cancers detected by screening mammography". Arch Intern Med. 168 (21): 2311–6. doi:10.1001/archinte.168.21.2311. PMID 19029493.
↑ Jatoi I, Anderson WF (2009). "Breast cancer overdiagnosis with screening mammography". Arch Intern Med. 169 (10): 999–1000, author reply 1000-1. doi:10.1001/archinternmed.2009.95. PMC 2768420. PMID 19468099.CS1 maint: PMC format (link)
↑ Breast Cancer. Cleveland Clinic (2015) http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/breast-cancer/ Accessed on January 18 2016
↑ Nottingham Prognostic Index. Wikipedia(2016) https://en.wikipedia.org/wiki/Nottingham_Prognostic_Index Accessed on january 16, 2016
↑ Breast Cancer. RadioPedia (2015) http://radiopaedia.org/articles/breast-cancer-staging Accessed on January 16, 2016

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[pmid19029493-1] Zahl PH, Maehlen J, Welch HG (2008). "The natural history of invasive breast cancers detected by screening mammography". Arch Intern Med. 168 (21): 2311–6. doi:10.1001/archinte.168.21.2311. PMID 19029493.

[pmid19468099-2] Jatoi I, Anderson WF (2009). "Breast cancer overdiagnosis with screening mammography". Arch Intern Med. 169 (10): 999–1000, author reply 1000-1. doi:10.1001/archinternmed.2009.95. PMC 2768420. PMID 19468099.CS1 maint: PMC format (link)

[adg-3] Breast Cancer. Cleveland Clinic (2015) http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/breast-cancer/ Accessed on January 18 2016

[NPI-4] Nottingham Prognostic Index. Wikipedia(2016) https://en.wikipedia.org/wiki/Nottingham_Prognostic_Index Accessed on january 16, 2016

[rp-5] Breast Cancer. RadioPedia (2015) http://radiopaedia.org/articles/breast-cancer-staging Accessed on January 16, 2016

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