Senior Consultant, Surgical Oncology, Fortis Hospital, Noida
Part 5 of 9 in Diagnosis and Management of Breast Cancer
Staging Breast Cancer and How Tumor Biology Drives Treatment Sequencing
November 17, 2024
Breast cancer is staged using the TNM system under NCCN guidelines, factoring tumor size, nodal status, and metastasis into stages running from stage 1 through stage 4.
Early, locally advanced, or metastatic
Clinically, cases fall into one of three categories: early breast cancer, covering stages 1, 2, and early stage 3; locally advanced breast cancer; and metastatic breast cancer. This distinction, more than the exact numeric stage, is what decides the overall shape of treatment.
Why biology decides the order of surgery and chemotherapy
For locally advanced disease, chemotherapy is given first, and surgery follows once the tumor has shrunk. For early breast cancer specifically, receptor status becomes the deciding factor: triple-negative and HER2-positive tumors receive neoadjuvant chemotherapy before surgery, while hormone-positive tumors go to surgery first, with chemotherapy afterward. Metastatic breast cancer is managed with chemotherapy as the primary treatment in most cases, since surgery on its own cannot address disease that has already spread.
This article is based on a Jivo Masterclass session conducted by Dr. Jalaj Baxi, Senior Consultant, Surgical Oncology, Fortis Hospital, Noida. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Jalaj Baxi taught doctors across Africa on November 17, 2024.
FROM THE LIVE Q&A
Moderator
On an evolutionary level, how does breast cancer differ between men and women?
Dr. Jalaj Baxi
There is no meaningful difference. The same hormone receptors, estrogen, progesterone, and HER2, apply in both male and female breast cancer, and treatment remains the same regardless of sex.
Frequently Asked Questions
Is there a correlation between certain cosmetics, such as talc or lipstick, and the development of breast cancer?▼
Various myths and misconceptions exist around this, including the use of talc in the axilla. Some print media point to possible links, but there is no confirmatory or corroborative evidence for a connection between cosmetics and breast cancer.
A 65-year-old woman has metastatic breast cancer and mastectomy is not feasible; she is currently on chemotherapy. What chemotherapy regimens are appropriate?▼
The regimen depends on the tumor's biology, specifically its ER, PR, and HER2 status. Treatment is usually a combination approach built around anthracycline-based chemotherapy along with hormonal therapy where relevant, and HER2-targeted therapy is added when HER2 is positive. A typical course runs six to eight cycles, though HER2-directed therapy in HER2-positive disease can extend to around 18 to 20 cycles.
Can chemotherapy be combined with hormonal therapy, and what other management plans and success rates apply in metastatic disease?▼
Yes, combining chemotherapy with hormonal therapy is possible. Further management depends on how the patient responds to treatment. Roughly 30 to 35% of metastatic breast cancer patients respond well, and where the response is strong enough, it can become possible to address the metastatic sites and the primary tumor surgically as well.
If a patient remains symptomatic after eight cycles of chemotherapy, what other treatment options are available?▼
Immunotherapy can be added, and second-line or third-line chemotherapy regimens are available, including CDK4/6 inhibitors. Next-generation sequencing of the tumor helps identify which newer targeted drugs are likely to be effective for that specific patient.
Why do many patients' health seem to deteriorate immediately after a breast cancer diagnosis?▼
This is largely psychological rather than driven by the disease itself, a kind of cancer phobia that sets in once the diagnosis is given, where the patient loses a sense of control over their own life and fears dying early or being treated inadequately. Educating patients about their specific disease and realistic treatment outcomes helps restore the sense that there is still a fight to be had, which improves how they cope.
What is the difference between early, locally advanced, and metastatic breast cancer?▼
Early breast cancer spans stages 1 through early stage 3; locally advanced breast cancer is a distinct clinical category treated with chemotherapy first; and metastatic breast cancer has already spread beyond the breast and axilla, managed primarily with chemotherapy.
Why do some early breast cancer patients get chemotherapy before surgery and others after?▼
It depends on receptor status: triple-negative and HER2-positive tumors receive chemotherapy before surgery (neoadjuvant), while hormone-positive tumors go to surgery first, with chemotherapy given afterward.
In This Series: Diagnosis and Management of Breast Cancer
- 1.Diagnosis and Management of Breast Cancer
- 2.How Breast Cancer Presents: Warning Signs Every Referring Doctor Should Know
- 3.The Triple Assessment: Clinical, Radiological and Pathological Workup
- 4.Biopsy Techniques and Receptor Testing in Breast Cancer
- 5.Staging Breast Cancer and How Tumor Biology Drives Treatment Sequencing
- 6.Breast Conservation Surgery vs Mastectomy: When Each Is Appropriate
- 7.Axillary Management: Lymph Node Dissection vs Sentinel Node Biopsy
- 8.Radiation Therapy After Breast Cancer Surgery: When It's Needed
- 9.Chemotherapy, Hormonal and Targeted Therapy: Regimens and Managing Metastatic Disease