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. Among multi gene panels only RS score (Oncotype DX) has been integrated into AJCC 8th edition of breast cancer staging system. It is recommended solely for the pathologic groupings of the patients whom surgery is the initial treatment for them. For more information please refer to the staging section of this chapter.
- Patients has been assigned to clinical prognosis stages with respect to the above-mentioned criteria.
Approach to determine the prognostic stage group of the patients according to the AJCC staging recommendations for breast cancer (8th edition)
Adopted and modified from AJCC 8th Edition staging system.
Other prognostic factors
In a nutshell, rather than classic TNM staging system, the following biological factors were incorporated into the prognostic staging system of the eighth edition of the AJCC staging manual:
- Estrogen receptor (ER) and progesterone receptor (PR) expression
- Human epidermal growth factor receptor 2 (HER2)
- Histologic grade
- Recurrence Score (RS):Oncotype DX
In addition to the above-mentioned factors, the AJCC mentioned several other factors that might help to determine the prognosis in patients with breast cancer, although the followings were not formally included in the current staging system:
- Ki-67 :
- Cellular proliferation and tumor balk marker
- Multigene expression assays other than RS:
- Mammaprint, EndoPredict, PAM50 Risk of Recurrence (ROR), and the Breast Cancer Index (level II evidence)
- Risk assessment models:
- Adjuvant! Online
- PREDICT-Plus
- Circulating tumor cells (CTCs):
- Cancer cells that separate from solid tumors and enter the bloodstream
- The cutoff for an unfavorable prognosis is ≥5 cells/7.5 mL
- Disseminated tumor cells (DTCs):
- Disseminated tumor cells in the bone marrow
- Might predict the likelihood of relapse at the time of initial tumor resection
- The relevant cutoff is ≥1 cell.
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.
- ↑ 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