When you or someone you love receives a breast cancer diagnosis, the next two questions are almost always: How advanced is the disease? And what are the treatment options?
With any type of cancer, how advanced the disease is – or what stage the disease is in – helps determine the best way to treat it.
Here we’ll go over how the breast cancer staging process works, what each stage means and what treatment options might look like at each stage.
If you’ve been diagnosed with breast cancer, this information can help you understand the possible treatment options that exist at each stage. But you should know that your personal preferences and goals are very important for deciding how you move forward. Your team of doctors and specialists will work with you to create a tailored breast cancer treatment plan.
How is breast cancer stage determined?
The breast cancer staging process helps doctors determine how much cancer there is and where it’s located. The higher the breast cancer stage number, the more advanced the disease.
Breast cancer staging is so important because it provides cancer care teams – which include breast surgeons, oncologists, pathologists, radiologists and many others – an agreed upon way to talk about the disease. This makes it easier for them to understand diagnoses and collaborate on treatment plans.
How the breast cancer staging process starts
The breast cancer staging process begins with diagnostic testing. Depending on previous screening results, if any breast cancer symptoms are present, and other factors, your doctor may recommend one of the following tests:
- Diagnostic mammogram – A mammogram involves using an X-ray to take photos of your breast tissue at different angles. To do this, your breasts are gently compressed between two plates so the X-ray can be taken.
- Ultrasound – An ultrasound is a non-invasive imaging test that bounces soundwaves of your breast tissue to create a picture of the inside of your breast.
- MRI – An MRI is another non-invasive imaging test that uses radio waves and a magnetic field to create an image of your breast tissue. This can help doctors determine the size and placement of tumors.
- Biopsy – A biopsy removes small masses and growths from your breast so they can be examined under a microscope by a pathologist and determine if they’re cancerous.
If cancer is detected, a CT scan may be ordered to look for any distant metastasis or local invasion to other organs. And you’ll likely be connected with a breast surgeon right away, either through a nurse navigator or your doctor.
Breast cancer staging guidelines
The TNM system is the most widely used cancer staging system and looks at the following cancer characteristics:
- Tumor (T) – The size of the tumor and whether it has grown into nearby tissue.
- Node (N) – Whether the cancer has spread to nearby lymph nodes. And if so, how many.
- Metastasis (M) – Indicates whether the cancer has spread to distant organs, like the lungs or liver.
But when it comes to breast cancer staging, the TNM system was expanded to include additional cancer characteristics, including:
- Estrogen-receptor status (ER) or progesterone-receptor status (PR) – Whether the cancer has estrogen or progesterone receptors. A positive status means the cancer can use either hormone to grow.
- HER2 status – Whether the cancer produces HER2, a protein that promotes the growth of cancer cells.
- Grade (G) – Indicates how much the cancer cells look like healthy cells.
- Oncotype DX recurrence score – Indicates how likely a group of genes may respond to treatment, depending on ER, PR and HER2 status. (This is considered only in certain circumstances.)
Determining the true stage of breast cancer
All the diagnostic tests and scans up to this point have been critical for helping your doctors understand your disease. But the exact stage of cancer can’t be determined until surgery happens – which is sometimes referred to surgical staging or pathological staging.
Breast surgery is usually the first step in Stages 0-2, and sometimes Stage 3 breast cancer. Surgery allows your surgeon to see what’s happening inside your body. It also allows them to remove cancerous tissues – which is an important step in preventing the cancer from spreading and determining next steps for your treatment.
If surgery can’t be done right away or at all, a clinical stage is given instead based on diagnostic imaging test results, biopsy pathology results, and a physical exam.
The stages of breast cancer and your treatment options
Compared to most other cancers, staging breast cancer is more complex. And when it comes to treating breast cancer, there isn’t a one-size-fits-all approach. Your treatment plan should be created especially for you and be coordinated across specialists – and that’s where your cancer care team comes in.
At HealthPartners, we believe cancer treatment and care is best managed by a group of doctors and specialists in what’s known as multidisciplinary conferences. This is where breast surgeons, oncologists, radiologists, pathologists and other members of your care team gather to discuss the best treatment sequence for you.
Below we dive into the treatment options your care team might recommend at various breast cancer stages.
Stage 0 breast cancer
What is Stage 0 breast cancer?
Stage 0 breast cancer is when the cells that line the milk ducts have become cancerous. This type of cancer is called ductal carcinoma in situ (DCIS), or non-invasive or pre-invasive breast cancer.
At this stage, the cancer has not spread to surrounding tissues. And while it’s considered non-invasive, it’s important to remember that it can still become invasive and spread beyond the milk ducts if it isn’t treated.
What are the treatment options for Stage 0 breast cancer?
- Surgery – Breast surgery is often the first step at Stage 0. Depending on the size of the tumor, how fast the cancer appears to be growing and your personal preferences, there are two types of surgical options:
- Lumpectomy – A lumpectomy is a targeted surgery that removes the lump or tumor in question, and a small amount of normal tissue around it. This is commonly referred to as breast conservation surgery (BCS). In the United States, most women with Stage 0 breast cancer undergo a lumpectomy followed by radiation therapy.
- Mastectomy – If the cancer has spread throughout the ducts and affects a large part of the breast, doctors may recommend a mastectomy. With this surgery, the entire breast is removed and possibly some lymph nodes as well.
- Radiation – If BCS is done, radiation is almost always recommended after surgery. The goal of radiation is to get rid of any cancer cells lingering in your breast and prevent them from coming back.
- Hormone therapy – If your cancer is hormone receptor-positive for estrogen or progesterone, your doctors may recommend hormone therapy treatment to help prevent cancer from returning.
What does the treatment timeline for Stage 0 breast cancer look like?
The treatment timeline can vary a little bit depending on the type of surgery you have. Lumpectomies are typically performed within the first month or so after a diagnosis, while mastectomies may take a little longer to get on the surgical schedule.
If whole breast radiation (the most common type) is needed post-surgery, that can add about four to six weeks to the treatment timeline. If hormone therapies are also recommended, you may take medications for several years.
In addition, your doctor may recommend more frequent breast cancer screenings in the future. A personal history of breast cancer means you’re at higher risk for another bout of the disease.
Stage 1 breast cancer
What is Stage 1 breast cancer?
Stage 1 breast cancers are still relatively small, and they’ve either not yet spread to the lymph nodes or there’s only been a tiny bit of spread in the sentinel lymph node – which is where the cancer is most likely to spread first. There are two types of Stage 1 breast cancer:
- Stage 1A – Stage 1A breast cancer means the tumor is no larger than 2 centimeters, and the cancer has not spread outside the breast or to lymph nodes.
- Stage 1B – Stage 1B breast cancer means there are small groups of cancer cells (between 0.2 and 2 millimeters) in the lymph nodes. There may or may not be a tumor smaller than 2 centimeters in the breast.
What are the treatment options for Stage 1 breast cancer?
- Surgery – Like with Stage 0, a lumpectomy and mastectomy are both options at this stage:
- Lumpectomy – This kind of breast conservation surgery is a viable option when the cancerous cells are confined to one area of the breast.
- Mastectomy – A mastectomy (of one or both breasts) may be recommended if cancer is found throughout the breast.
- Radiation – Similar to Stage 0, radiation will likely be recommended after breast conservation surgery. Depending on your type of cancer, radiation may be recommended after a mastectomy, but it’s not very less likely at this stage. The goal of radiation is to kill any remaining cancer cells in the chest or lymph nodes to prevent them from spreading or coming back.
- Chemotherapy – Depending on a variety of factors like how big the tumor is, how fast the cancer may be growing and your age, chemotherapy may be recommended after surgery to help kill cancer cells throughout your body.
- Targeted therapies – Depending on your cancer’s specific characteristics such as HER2 status and tumor size, targeted drug therapies may also be recommended to control and treat your cancer.
- Hormone therapy – As with Stage 0, if your cancer is hormone receptor-positive, hormone therapy may be recommended after surgery and other treatments. At this stage, this therapy can help slow or stop the growth of cancer cells, and reduce the risk of cancer returning.
Stage 1 breast cancer treatment timeline
Timing will vary based on the type of surgery you have and which additional therapies are recommended as part of your treatment plan. Generally speaking, treatment for Stage 1 breast cancer lasts between one and six months. Again, if hormone therapy is also recommended, you may be taking medications for several years to prevent the cancer from coming back.
Stage 2 breast cancer
What is Stage 2 breast cancer?
Stage 2 breast cancer cells or tumors are larger than Stage 1 cancers, and may have spread to nearby lymph nodes. There are two types of Stage 2 breast cancer:
- Stage 2A – Generally speaking, Stage 2A breast cancer can indicate one of the following:
- No tumor can be found in your breast, but cancer larger than 2 millimeters can be found in one to three underarm (axillary) lymph nodes or near the breastbone.
- The tumor measures 2 centimeters or smaller, and has spread the nearby axillary lymph nodes.
- The cancer has not spread to area lymph nodes, however, the tumor measures between 2 and 5 centimeters.
- Stage 2B – Stage 2B breast cancer can generally mean:
- The tumor is between 2 and 5 centimeters, and a small group of cells are found in the lymph nodes.
- The tumor is between 2 and 5 centimeters, and the cancer has spread to one to three axillary lymph nodes or lymph nodes near the breast bone.
- The tumor is larger than 5 centimeters but it hasn’t spread to nearby lymph nodes.
What are the treatment options for Stage 2 breast cancer?
- Surgery – Similar to Stages 0 and 1, surgery is often a first step. A lumpectomy or mastectomy are both options at this stage, and the option that’s best for you will depend on several factors like type of cancer and your age.
- Radiation – In earlier stages, radiation is usually only recommended after breast conservation surgery. But with Stage 2 breast cancer, radiation is often recommended after mastectomies if the cancer is found in the lymph nodes during surgery. At this stage, radiation can help destroy any remaining cancer cells and help prevent them from spreading or coming back.
- Chemotherapy – Depending on the type of cancer, chemotherapy may be recommended before or after surgery. Chemotherapy is a systemic therapy used to kill cancer cells throughout the body. As with other therapies, hormone receptor status, HER2 status and gene panel results can help determine whether chemotherapy would be beneficial.
- Targeted therapies – As with Stage 1, depending on your cancer’s specific characteristics, other targeted drug therapies may also be recommended to control and treat your cancer.
- Hormone therapy – Hormone therapy may be recommended before and after surgery along with other treatments to help reduce the risk of the cancer returning.
Stage 2 breast cancer treatment timeline
Again, it depends on what treatments or follow-up therapies are needed. Generally, the treatment timeline for Stage 2 breast cancer can last three to six months. Again, certain treatments – like hormone therapies designed to stop the cancer from coming back – can last for one to 10 years.
Stage 3 breast cancer
What is Stage 3 breast cancer?
Stage 3 breast cancer is when tumors are larger than earlier stages or are growing into nearby tissues, and the cancer has spread to nearby lymph nodes. There are three categories of Stage 3 breast cancer:
- Stage 3A – In some cases, Stage 3A breast cancer indicates that the cancer spread to four to nine area lymph nodes, and there may or may not be a tumor in the breast. In other cases, it can describe a cancer that has spread less but the tumor is larger than 5 centimeters.
- Stage 3B – Stage 3B breast cancer can mean that the cancer has spread to the chest wall or to the breast’s skin, causing swelling or an ulcer. It may also mean that cancer has spread to up to nine axillary lymph nodes or lymph nodes near the breast bone.
- Stage 3C – Stage 3C breast cancer means the cancer may have spread to the chest wall or breast’s skin, or it has spread to 10 or more nearby lymph nodes. It can also mean the cancer has also spread to lymph nodes above or below the collarbone.
What are the treatment options for Stage 3 breast cancer?
- Chemotherapy – In most cases, chemotherapy is the first step for Stage 3 breast cancers, followed by surgery and other treatments. Chemotherapy helps destroy cancer cells throughout the body.
- Surgery – While a lumpectomy can be an option in some cases at this stage, a mastectomy is most likely. That’s because the tumors have grown to be relatively large and have also grown into nearby tissues. Depending on your cancer, surgery can happen before, but usually happens after chemotherapy.
- Radiation – Radiation is almost always recommended after surgery during this stage, helping to destroy any remaining cancer cells in the chest or lymph nodes, and prevent them from spreading further.
- Hormone therapy – As with other stages, hormone therapy may be recommended depending on your HER2 status and hormone receptor status. This type of therapy may also be recommended before surgery and alongside chemotherapy, and likely continue after surgery and beyond.
Stage 3 breast cancer treatment timeline
The treatment timeline for Stage 3 breast cancer depends greatly on the severity, extent of spreading, the type of treatment you’re undergoing and how you’re responding to those treatments. For most Stage 3 cases, treatment can last anywhere from six to 12 months – with hormone therapy lasting many years after.
Stage 4 breast cancer
What is Stage 4 breast cancer?
In Stage 4, the breast cancer has metastasized, which means the disease has spread to distant parts of your body. When breast cancer spreads, it can often invade the lungs, liver and bones, sometimes making its way to the brain or other organs.
What are the treatment options for Stage 4 breast cancer?
- Systemic therapies – A combination of systemic therapies are often recommended at specific times during the treatment of Stages 1-3. But in stage four, these therapies are the primary treatment and include:
- Hormone therapy – This type of therapy can help slow or stop the growth of cancerous cells.
- Chemotherapy – This therapy can destroy cancerous cells throughout your body.
- Targeted drug therapies – Like chemotherapy, these targeted drugs help reach cancer in distant areas of the body. But depending on your type of cancer, HER2 status and hormone receptor status, different targeted drugs can work alongside chemotherapy or even better than chemotherapy.
- Immunotherapy – This therapy helps raise your body’s natural immune response to fight of the cancer.
- Surgery and radiation – During the most advanced stages of breast cancer, surgery and radiation are only recommend under specific circumstances, including:
- When the breast tumor is causing an open wound in the breast (or chest)
- To treat a small number of metastases in a certain area, such as the brain
- To help prevent bone fractures
- When an area of cancer spread is pressing on the spinal cord
- To treat a blood vessel blockage in the liver
- To provide relief of pain or other symptoms
- Pain management – For severe pain in late-stage breast cancer, a doctor may prescribe a medicine to make the pain tolerable. The goal of pain management is to offer the most pain control using the least amount of medicine.
Stage 4 breast cancer treatment timeline?
It depends on the diagnosis and how the patient responds to treatment. In most cases, Stage 4 cancer is not curable. Treatment may still be used to improve the patient’s quality of life and help them live longer, however. Some people diagnosed with Stage 4 breast cancer continue to lead active lives more than a decade after their diagnosis.
Want to learn more about your breast cancer treatment options? We’re here for you.
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