Breast cancer used to be staged according to the TNM system. Recently, the American Joint Committee on Cancer (AJCC) Staging Manual (8th edition, last updated 1/25/2018) extensively revised their staging system. The 8th edition of the AJCC TNM breast cancer staging system delivers a flexible platform for prognostic classification based on traditional anatomic factors, which may be modified and enhanced with respect to patient biomarkers and other prognostic panel data. Nevertheless, in order to maintain worldwide value, AJCC tumor staging system remained based on classic TNM anatomic factors. Prognosis is closely linked to results of staging, and staging is also used to allocate patients to treatments both in clinical trials and clinical practice.
The 8th edition of the AJCC TNM breast cancer staging system delivers a flexible platform for prognostic classification based on traditional anatomic factors, which may be modified and enhanced with respect to patient biomarkers and other prognostic panel data.[1]
Nevertheless, in order to maintain worldwide value, AJCC tumor staging system remained based on the classic TNM anatomic factors.
Major changes in the 8th edition of AJCC TNM staging system were discussed below.[2]
AJCC panel incorporated biologic factors into the staging system as follows:
For small hormone receptor-positive tumors that have not spread to more than 3 lymph nodes
Also may be used for more advanced tumors
Might be used for DCIS (ductal carcinoma in situ or stage 0 breast cancer). as well looks at a set of 21 genes in tumor biopsy samples to get a “recurrence score,” which is a number between 0 and 100.
The score reflects the risk of breast cancer coming back (recurring) in the next 10 years and how likely you will benefit from getting chemo after surgery.
The lower the score (usually 0-10) the lower the risk of recurrence.
Benefit from chemotherapy is in doubt in most women with low scores
An intermediate score (usually 11-25): intermediate risk of recurrence.
Benefit from chemotherapy is in doubt in most women with intermediate-recurrence scores,
Nevertheless chemotherapy is believed to be beneficial for women younger than 50 with a higher intermediate score (16-25)
The possible risks and benefits of chemo should be weighted and discussed prior to decision making.
A high score (usually 26-100): higher risk of recurrence.Chemotherapy is recommended for women with high scores in order to help lower the chance of cancer *recurrence.
OncotypeDx is the only multigene panel with level I of evidence, and hence has been incorporated in the AJCC staging system
MammaPrint®:
To determine the likelihood of cancer recurrence in a distant part of the body after treatment.
May be used in any type of breast cancer with stage 1 or 2 that has spread to no more than 3 lymph nodes.
Hormone and HER2 status are also evaluated in this test. Seventy different genes are examined in this test to determine the 10 years cancer recurrence
The test results are reported as either “low risk” or “high risk.”
Unlike OncotypeDx has not been incorporated in the AJCC staging systemyet.
According to the AJCC statement "Content is available for user's personal use. It can not be sold, published or incorporated into any software, product or publication with a written license agreement with ACS." Hence, we may not provide the details of their recent staging system here.
You may find more information for your personal use here.
Breast carcinoma TNM anatomic stage group[edit | edit source]
This system is solely recommended for countries with no/limited access to the other mentioned biochemical and genetic tests.
This system is the classic Tumor(T) Lymph Node(N), Metastasis (M) system.
In a nutshell, rather than classic TNM staging system, the following biological factors were incorporated into the prognostic staging system of the eighth edition of the AJCC staging manual:
Estrogen receptor (ER) and progesterone receptor (PR) expression
Human epidermal growth factor receptor 2 (HER2)
Histologic grade
Recurrence Score (RS):Oncotype DX
In addition to the above-mentioned factors, the AJCC mentioned several other factors that might help to determine the prognosis in patients with breast cancer, although the followings were not formally included in the current staging system:
Ki-67 :
Cellular proliferation and tumor balk marker
Multigene expression assays other than RS:
Mammaprint, EndoPredict, PAM50 Risk of Recurrence (ROR), and the Breast Cancer Index (level II evidence)
Risk assessment models:
Adjuvant! Online
PREDICT-Plus
Circulating tumor cells (CTCs):
Cancer cells that separate from solid tumors and enter the bloodstream
The cutoff for an unfavorable prognosis is ≥5 cells/7.5 mL
Disseminated tumor cells (DTCs):
Disseminated tumor cells in the bone marrow
Might predict the likelihood of relapse at the time of initial tumor resection