The purpose of this article is to help explain what is involved in the staging process, what types of procedures and tests you might need as part of staging, and what this means to you, as a patient.
Worldwide, breast cancer is the most common malignancy diagnosed in women, and the second leading cause of cancer mortality among women (1). In cancer the body's cells become abnormal and divide without control. Cancer cells may invade nearby tissues. And they may spread through the bloodstream and lymphatic system to other parts of the body. When a man or woman is diagnosed with breast cancer, many fears and questions will come to mind. They will want to know the best treatment. What many do not know is that their treatment will vary greatly, depending on the type of breast cancer, and on the extent, or stage, of the disease.

What is staging?
Staging is a term or descriptor used to describe the extent of cancer spread. Cancer staging is based on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast. Depending on the size of the tumor, the involvement of lymph nodes with cancer, and whether or not cancer has spread to distant areas such as the lung, liver or bones, will determine what stage of cancer you have.



Why is staging helpful?

Staging is useful in the following ways:

• determining your choice of treatment
• estimating your prognosis (the most likely outcome of the disease).
• staging provides a universal common language with which doctors, nurses and patients may understand the cancer and the response of that cancer to treatment.

How is Staging Performed?

We know that the stage of a cancer is based on the size of the tumor, whether or not lymph nodes are involved, and whether or not cancer has spread beyond the breast to distant organs such as the bone or lungs.

The size of a tumor may be measured by physical exam and by imaging studies such as mammogram, ultrasound, or magnetic resonance imaging (MRI). The most accurate measurement of a tumor's size is at the time of definitive surgery, once the cancer has been completely removed. Below is a chart which will help you understand size of a cancer.  The type of cancer (either in situ or invasive) is determined at the time of the tumor biopsy or surgical procedure. Many specific characteristics of the tumor are noted at the time of a biopsy; specific tests are run on the tumor by the laboratory. These tests provide particular specific information about the tumor. In order to further determine the extent of cancer, your surgeon may need to evaluate the lymph nodes of the armpit area (axilla).

How will my doctor know if a lump in my breast is cancer, and what type of cancer?

Your doctor may do something called a Core Needle Biopsy (CNB). In this procedure a small sample of breast tissue is removed so it may then be analyzed. A lot of information is obtained from this procedure, including type of cancer and characteristics of the cancer. Below is a diagram illustrating a core needle biopsy (CNB).

What do I need to understand about the lymphatic system of the breast?

Cancer cells may travel from the breast to small structures called lymph nodes. The armpit is the primary site of drainage of the breast in most breast cancer cases. Much less commonly, drainage of lymph from the breast goes to lymph nodes in the chest (Image 3). Once tumor cells travel to the lymph nodes, the stage of the cancer is more advanced. Physical examination of the armpit, or axilla, may reveal an abnormal lymph node. Similarly, an abnormality noted on imaging may indicate that further evaluation of a lymph node is indicated.

How will my surgeon evaluate the lymph nodes to look for cancer cells?

Knowing whether or not cancer cells have traveled from the breast to the lymph nodes is very important. Below are some ways your surgeon will evaluate the lymph nodes.

Fine Needle Aspiration (FNA) of a Lymph Node

A needle is inserted into a lymph node that feels enlarged or abnormal. Cells are withdrawn and looked at under a microscope so see if they are malignant, or cancerous. If physical examination and imaging have not revealed a suspicious lymph node, this procedure is not routinely performed. The FNA procedure is done in the surgeon’s or radiologist’s office on an outpatient basis, and takes only a few minutes to perform. If cancer cells are found in the lymph node, further evaluation of the remaining axillary lymph nodes will be required.

Sentinel Lymph Node Dissection

In this operation, your surgeon removes only the “sentinel” nodes. These are the nodes that are the first to receive and harbor cancer cells. Usually between one and four lymph nodes are removed with this procedure. If no cancer is found in the sentinel node, you may be spared a more invasive staging procedure. If tumor cells are found in the sentinel node, you may need further surgery to remove more lymph nodes from the armpit area. Below is a diagram showing the Sentinel Lymph Node Biopsy procedure (Image 4).

Axillary Lymph Node Dissection

If cancer cells are detected on a fine needle or core needle biopsy, or during a sentinel lymph node biopsy, your surgeon may need to perform what is called an axillary lymph node dissection. This operation is done so that some lymph nodes from the armpit may be fully evaluated for extent of cancer. This gives you and your doctor a more accurate measure of the extent of the spread of the breast cancer.

Where else can cancer go?

The following illustration shows where breast cancer can go if it leaves the local (breast) area.

What other tests might I need in order to stage my cancer?

To gather the necessary information, your doctor will ask questions about your medical history, do a careful physical examination, and review all the tests you've had. This also can include review of the results from the biopsy of the tumor or suspicious area. If you've already had surgery to remove your cancer and sample your lymph nodes for cancer cells, your doctor will use information from your pathology report. Some additional tests may be needed, but most women with a new diagnosis of breast cancer don't need all the diagnostic tests available. Staging tests include:

• Blood tests. Blood tests might include a complete blood count and a blood chemistry test, which assess your kidney and liver function. Blood tests known as tumor markers aren't used for staging breast cancer, as they haven't been proved to reliably show the presence or absence of breast cancer cells. Another blood test called a circulating tumor cell assay is being developed but isn't yet routinely used.
• Chest X-ray. A chest X-ray may reveal whether breast cancer cells have spread to your lungs.
• Additional imaging tests. Additional imaging can be used to look for breast cancer cells that have spread to other areas of your body. Not everyone with breast cancer needs these tests, though, so ask your doctor what's best for you. Additional imaging tests include a bone scan, computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET).

The staging process has been completed. How do I know what "stage" I am?

Breast cancer stages range from zero to four (0 to 4), with many subcategories. Lower numbers indicate earlier stages of cancer, while higher numbers reflect late-stage cancers.

The table below shows a simplified Breast Cancer staging system

Progression and Staging of Breast Cancer
Stage	Description
0	Abnormal cells in the lining of the ducts or sections of the breast
	Results in increased risk of developing cancer in both breasts
1	Cancer in breast tissue tumor less than 2 cm across
2	Cancer in breast tissue tumor less than 5 cm across
	Cancer may also spread to axillary (armpit) lymph nodes
3	Tumor is larger than 5 cm across with extensive spread to axillary or other nearby lymph nodes
	Possible inflammation of breast tissue, dimpling, thickening, and change in color of the skin due to blocked lymphatic drainage
4	Spread of cancer beyond the immediate region of the breast

I'd like to know a little more detail about the different stages of breast cancer.

Below is a description, stage by stage, of specific stages of breast cancer.

Stage 0

This stage describes noninvasive (in situ) breast cancer. Ductal carcinoma in situ (DCIS) is an example of stage 0 cancer.

Stage I
This stage is an early stage of invasive breast cancer in which:

· The tumor measures no more than 2 centimeters (cm) in diameter (3/4 inch)

· No lymph nodes are involved.

Stage II
This stage describes invasive breast cancers in which one of the following is true:

· The tumor measures less than 2 cm (3/4 inch) but has spread to lymph nodes under the arm.

· No tumor is found in the breast, but breast cancer cells are found in lymph nodes under the arm.

· The tumor is between 2 and 5 cm (about 3/4 to 2 inches) and may or may not have spread to lymph nodes under the arm.

· The tumor is larger than 5 cm (2 inches) but hasn't spread to any lymph nodes.

Stage III

Stage III breast cancers are subdivided into three categories — IIIA, IIIB and IIIC based on a number of criteria. By definition, stage III cancers haven't been identified in distant sites.

For example, a stage IIIA tumor is larger than 5 cm (2 inches) and has spread to one to three lymph nodes under the arm. Other stage IIIA tumors may be any size and have spread into multiple lymph nodes. The lymph nodes clump and attach to one another or to the surrounding tissue.

In stage IIIB breast cancer, a tumor of any size has spread to tissues near the breast — the skin and chest muscles — and may have spread to lymph nodes within the breast or under the arm. Stage IIIB also includes inflammatory breast cancer, an uncommon but aggressive type of breast cancer.

Stage IIIC cancer is a tumor of any size that has spread:

· To 10 or more lymph nodes under the arm

· To lymph nodes above or beneath the collarbone and near the neck

· To lymph nodes within the breast itself and to lymph nodes under the arm

Stage IV

Stage IV breast cancer has spread to distant parts of the body, such as the lungs, liver, bones or brain.

Q: What does it all mean? When should all the staging be done and how

long should I expect this process to take?

A: The staging process actually begins right away- at the time your cancer is diagnosed. The amount of time and the number and type of procedures required to complete the staging process will vary depending on your type of breast cancer. Sometimes it takes several weeks before you know your final cancer stage, and you may need several procedures or tests to gain all the information required to accurately stage your cancer.

The treatment plan will then be tailored to you and your stage of cancer. Your surgeon will refer you to specialists for additional treatments depending on the stage of cancer. Depending on tumor type and stage, you may need chemotherapy, surgery, or radiation first. Your doctor will guide you.

It is a good idea to keep a list of your questions as you go through different tests and treatments; it is helpful to ask your questions as they arise. Your doctor and his or her whole health care team are prepared to address all of your questions, and your concerns and fears.

It is important to be hopeful, and to know that even the more advanced stages of breast cancer are very treatable.

For further staging information, you may consider the following websites:

1) http://www.cancerstaging.net

2) http://www.breastcancer.org

REFFERENCES
1. American Cancer Society Global Cancer Estimated Facts and Figures 2009.
2. AJCC American Joint Committee on Cancer 7th Edition. Edge S, Byrd D, Compton C, et al. Springer-Verlag, New York, NY. January 2010.

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