1.4 Staging & Grading Breast Cancer

1.4.1 Pathology Reports

Pathology reports are documents you will receive after a tumour biopsy (BC Cancer, n.d.12). This report provides information regarding your tumour, including the type, stage, and grade. All of this information is important to determine what is happening in your body and the treatment options with the best outcomes for your breast cancer.

Hormone Receptor Status

Estrogen and progesterone are female hormones that can stimulate the growth of some cells, including breast cancer cells (Canadian Cancer Society, n.d.y). Normal breast cells and some types of breast cancer cells have estrogen receptors (ER) and progesterone receptors (PR) on their surface or inside.

Hormone status tells doctors if hormonal therapy is likely to slow or stop the cancer cells from growing (Canadian Cancer Society, n.d.y).

Check out the following resource for more information on hormone receptor status:

1.4.2 What is Staging?

Staging refers to the stage of cancer you are currently in. According to the National Cancer Institute (NCI), a cancer’s stage is determined by a variety of factors, including:

• the location of the tumour,
• the size of the tumour,
• whether the cancer has spread to nearby lymph nodes,
• and whether the cancer has spread to a different part of the body. (NCI, 2022a)

Staging breast cancer is important for determining the best treatment plan.

1.4.3 Staging Systems

In Canada, the TNM system is often used to stage breast cancer. TNM stands for:

1. Tumour — what is the size of the tumour? Has is affected the surrounding skin or chest wall?
2. Lymph node — has the cancer affected the lymph nodes? If so, how many?
3. Metastasis — has the cancer spread to other organs? (Canadian Breast Cancer Network [CBCN], 2022)

After considering the above three factors, your TNM stage translates to a clinical stage; clinical stages range from stage 0 (cancer limited to the breast) to stage IV (cancer has spread to other organs) (CBCN, 2022). The lower the stage of breast cancer, the higher the chance of survival and the lower the chance of recurrence.

Various tests can stage breast cancer, including X-rays, computed tomography scans, auxiliary lymph node dissection, and bone scans (CBCN, 2022).

1.4.4 Stages of Breast Cancer

There are five different stages of breast cancer:

• Stage 0 — the cancer is not invading any surrounding structures (e.g., tissue) and is still inside the milk duct.
• Stage I — the cancer has not spread far into the lymph nodes, and if it has, it is in the sentinel lymph node.
• Stage II — the cancer has spread to some nearby lymph nodes.
• Stage III — the cancer has spread into the surrounding tissue and or many nearby lymph nodes.
• Stage IV — the cancer has spread into different parts of your body (metastasized). (American Cancer Society, 2019)

1.4.5 What is Grading?

Tumours are graded according to what the cancer cells look like under a microscope (CBCN, 2022). There are three characteristics to consider:

1. Mitotic activity — are the cancer cells in the process of dividing? If so, there is high mitotic activity.
2. Tubule formation — are the cancer cells still forming tubules like normal breast cells? If not, they can be more aggressive.
3. Nuclear pleomorphism — are the cancer cells’ nuclei varied in size and shape? If so, there is less differentiation. (CBCN, 2022)

Your tumour grade is a combination of the score of each characteristic listed above (CBCN, 2022). Tumour grades are on a scale of one to three, with one being the least aggressive and three being the most. However, remember that staging and grading are two scores, and you can have differing scores within these categories.

Finding out what grade of tumour you have can help you and your health-care team figure out the best treatment plan for your breast cancer.

1.4.6 Triple Assessment

Triple assessment for breast cancer is a standardized practice used to decrease the chance of error during the diagnostic process and give a more accurate assessment (Karim et al., 2020). This assessment involves three categories of testing:

• physical examination,
• imaging (e.g., mammograms),
• and biopsies (e.g., fine needle aspiration) (Karim et al., 2020).

Conducting all three assessments has been found to increase the chance of diagnosing breast cancer compared to only doing one or two of these tests (Karim et al., 2020). Triple assessment helps ensure that your healthcare team does not miss the breast cancer.

1.4.7 Waiting Time for Diagnosis

Typically, normal results are returned about three weeks after your initial breast cancer screening (BC Cancer, n.d.22). If results are abnormal, then you will be contacted sooner for further testing to determine if it is cancer or not.

If you are diagnosed with breast cancer, you will receive diagnostic testing that will help to determine the stage and grade of cancer. This testing will allow your healthcare team to make informed decisions about treatment plans (CBCN, 2022).

1.4.8 When to Start Treatment

After a breast cancer diagnosis, you may feel like you need to start treatment as soon as possible (Canadian Cancer Society, n.d.6). However, this urgency is unnecessary unless your healthcare team recommends immediate treatment.

Waiting times for treatment can vary depending on a few factors, including the type of treatment and how advanced the cancer is (Canadian Cancer Society, n.d.6). Your healthcare team also needs time to conduct additional testing to analyze the breast cancer further.

It is important to note that delays in receiving treatment do not always negatively impact the treatment’s outcome (Bleicher, 2018). Experts recommend having surgery within 90 days of diagnosis. Treatment plans that include chemotherapy or radiation should be done within 120 days and 365 days, respectively. While certain situations are time-sensitive, most individuals have a few weeks to understand their diagnosis and organize themselves before deciding on treatment.

Before your treatment begins, take care of all aspects of your health, including emotionally, mentally, and physically (Canadian Cancer Society, n.d.6). Take this time to relax, eat healthy foods, exercise, and do things you enjoy.

1.4.9 Timeline for Treatment in BC

In 2019, British Columbia had 4170 diagnoses of breast cancer (BC Cancer, 2022a).

From September 1, 2022, to November 30, 2022, these were the surgery wait times for breast biopsies and mastectomies for three BC communities, according to the Government of British Columbia (n.d.b, n.d.c).

Kamloops

For breast biopsies, 50% were completed within 3.6 weeks, and 90% were completed within 7.9 weeks (Government of British Columbia, n.d.b). For mastectomies, 50% were completed within 3.3 weeks, and 90% were completed within 7.5 weeks (Government of British Columbia, n.b.c). At Kamloops’ Royal Inland Hospital specifically, 50% of mastectomies were completed within 4.0 weeks, and 90% were completed within 7.5 weeks.

Kelowna

For breast biopsies, 50% were completed within 3.6 weeks, and 90% were completed within 7.9 weeks (Government of British Columbia, n.d.b). For mastectomies, 50% were completed within 3.3 weeks, and 90% were completed within 7.5 weeks (Government of British Columbia, n.b.c). At Kelowna General Hospital specifically, 50% of mastectomies were completed within 3.0 weeks, and 90% were completed within 7.7 weeks.

Abbotsford

For breast biopsies, 50% were completed within 2.9 weeks, and 90% were completed within 6.6 weeks (Government of British Columbia, n.d.b). For mastectomies, 50% were completed within 2.4 weeks, and 90% were completed within 9.1 weeks (Government of British Columbia, n.b.c). At Abbotsford Regional Hospital and Cancer Centre specifically, 50% of mastectomies were completed within 2.1 weeks, and 90% were completed within 3.4 weeks.