Marianne, an oncology nurse navigator, is preparing a cancer treatment summary and survivorship care plan for Sylvia, who finished breast cancer treatment six weeks ago. Sylvia was treated with neoadjuvant therapy followed by mastectomy, reconstruction, and radiation. Her tumor was characterized as multifocal invasive ductal carcinoma, grade 2, estrogen and progesterone positive, and HER2/neu negative. Sylvia has no family history of breast cancer. Marianne notices that the oncologist recorded Sylvia’s cancer as a stage IB. Marianne wonders if the stage was determined before or after chemotherapy and surgery.
What Would You Do?
Marianne discusses her question with the medical oncologist, who shows her where to find the final staging in the electronic health record and explains the American Joint Committee on Cancer’s (AJCC’s) eighth edition staging criteria, which adds four characteristics to the familiar TNM breast cancer staging criteria:
- Estrogen receptor status
- Progesterone receptor status
- HER2/neu status
- Cancer grade
Be aware that different criteria are used to stage breast sarcomas, malignant Phyllodes tumors, and breast lymphomas.
A tumor is considered classified when it is assigned a stage. Some disease sites such as breast and prostate cancer have additional subcategories represented by letters—A, B, or C. Using Sylvia’s case as an example, the following criteria resulted in an AJCC stage IB breast cancer:
- Tumor size: > 20 mm but ≥ 50 mm in greatest dimension, ypT2
- Lymph node status: 4 out of 16 nodes positive, ypN2a
- Metastasis: none noted on pretreatment positron emission tomography scan, cM0
- Estrogen receptor: strongly positive, 100% of stained cells
- Progesterone receptor: strongly positive, 80% of stained cells
- HER2/neu receptor: negative by fluorescence in situ hybridization
- Grade: well-differentiated grade 2
Likewise, AJCC now uses prostate specific antigen and grade (based on Gleason score and Gleason pattern) for prostate cancer staging. The various factors related to cancer staging have evolved and demonstrate the personalization of cancer care.