Patients with breast cancer will commonly present in one of two ways:
- Self detected breast mass
- Screen detected breast lesion
Less commonly, patients will present with:
- Nipple discharge
- Inflammatory breast cancer
- Neglected breast cancer with skin breakdown
- Metastatic disease
In radiation oncology, patients will usually be referred after surgical intervention, before or during systemic therapy (if prescribed)
History
The age of the patient is particularly important, especially since breast cancer has the potential for very late recurrences (after 10-15 years). Patients with a limited life expectancy may not benefit as much from adjuvant treatment as those who are young and fit.
Presenting Complaint
The mode of presentation should be known (self detected, screen or other). The date of detection and surgery should be recorded, as should any complications arising from it (eg. seroma, wound infection). If chemotherapy is proposed, then the type, starting date and likely completion date should be known.
If metastatic disease has developed, then the patient's current symptoms should be identified to determine whether radiotherapy is an appropriate treatment.
Past Medical History
There are two important groups of past medical problems:
- Medical problems which will impact on life expectancy, such as severe cardiac or respiratory disease.
- Medical problems which will interact badly with radiotherapy, such as rheumatoid arthritis or systemic lupus erythematosus.
Past Surgical History
No specific questions
Past Radiotherapy
Any previous radiotherapy should be inquired about
Past O&G History
The length of time a woman has experienced cycling hormone levels (menstrual cycle) is thought to be related to the risk of breast cancer. Therefore, the following points should be identified:
- Number of pregnancies and deliveries (Gx Px)
- Age of menarche
- Menopausal status (pre-, peri- or post, with year of menopause recorded)
- Menopausal status influences the choice of hormonal therapy
Medications
Should be recorded, particularly if the patient has already started on hormonal therapy. Any medications that may impact on the effect of radiotherapy should be noted, especially methotrexate.
Allergies
No specific questions
Family History
About 5% of breast cancers may have a familial component, usually suggested by:
- Early age of onset
- 1st degree relatives with breast cancer
- Male patient with breast cancer
Ideally, a genogram should be created for every patient, identifying family members with malignancies. This can help to identify the presence of a familial genetic abnormality.
Social History
The patient's ability to attend treatment should be explored. Many patients can continue to work during the first few weeks of treatment, particularly in office jobs. Social supports are important.
Examination
Examination is similar for most new patients:
- Examination of the affected breast (or chest wall)
- Examination of the contralateral breast
- Examination of regional nodes (axilla, supraclaviular) bilaterally
- Examination of chest, abdomen (for detection of distant disease)
Percussion of the spine is done by some consultants.
Investigations
Bloods
Routine bloods should include:
- FBE - Full Blood Examination
- UEC - Electrolytes, Urea and Creatinine
- LFT - Liver function tests (potentially deranged with liver metastases)
- CMP - Calcium, Magnesium, and Phosphate (potentially deranged in advanced disease)
Tumour Markers
Pending
Imaging
If a patient presents with a clinically detected mass they should be investigated with bilateral mammography followed by ultrasound of suspicious lesions.
Further imaging to stage distant disease is controversial. A set of evidence based guidelines, based on the likelihood of positive results and false negative rates of investigations, recommends:
- No systemic staging for clinical stage I disease
- Whole body bone scan for clinical stage II disease
- Whole body bone scan, liver ultrasound and chest x-ray for stage III disease
If a patient presents with symptoms related to metastases then they should be appropriately imaged.
Histopathology
The excision of the breast cancer lesion provides important diagnostic and prognostic information, including:
- The size of the tumour, and whether it is multifocal/multicentric
- The histological grade and type of tumour (ductal, lobular, etc)
- The presence of lymphovascular or perineural invasion
- The status of surgical margins
- The presence of DCIS/LCIS with the invasive tumour
Lymph nodes are usually included in a resection. These may be:
- Sentinel nodes (determined by injection of radionuclide and dye) and/or
- Axillary clearance (removal of all level I and II lymph nodes from the axilla)
The presence of malignancy in lymph nodes is perhaps the most important prognostic indicator.
Staging
Breast cancer is staged using the AJCC/UICC TNM system.
T Stage
T0 - No evidence of primary
Tis - in situ disease with no invasion present
- Tis (DCIS or LCIS) - Ductal or Lobular Carcinoma in situ
- Tis (Paget's) - Paget's disease of the nipple with no invasive tumour
T1 - Invasive disease ≤ 20 mm
- T1mi - Invasive disease ≤ 1 mm diameter (microinvasive disease)
- T1a - Invasive disease > 1 mm but ≤ 5 mm
- T1b - Invasive disease > 5 mm but ≤ 10 mm
- T1c - Invasive disease > 10 mm but ≤ 20 mm
T2 - Invasive disease > 20 mm but ≤ 50 mm
T3 - Invasive disease > 50 mm
T4 - Invasive disease that involves the overlying skin or underlying chest wall
- T4a - Invasive disease that invades the chest wall - this does not include invasion of pectoralis mucles
- T4b - Invasive disease that causes skin ulceration or oedema, or presents with ipsilateral satellite skin nodules
- T4c - T4a and T4b
- T4d - Inflammatory carcinoma
N stage
Nodal stage is divided into clinical staging (palpation/imaging) or pathologic stage (sentinel node biopsy or axillary clearance). Pathological staging is the usual method of determining the need for axillary or supraclavicular radiation.
Clinical N Stage
NX - Nodes unable to be assessed clinically (due to prior removal in most cases)
N0 - No evidence of involved lymph nodes
N1 - Metastases to mobile, ipsilateral axillary lymph nodes (levels I and II only)
N2a - Metastases to matted axillary lymph nodes (levels I and II only)
N2b - Metastases to ipsilateral internal thoracic nodes WITHOUT metastases to axillary nodes
N3a - Metastases to ipsilateral level III axillary nodes (apical or 'infraclavicular')
N3b - Metastases to both axillary AND internal thoracic nodes
N3c - Metastases to ipsilateral supraclavicular lymph nodes
Pathological N Stage
NX - Nodes unable to be assessed pathologically
N0 - No evidence of nodal metastases on histological examination. Note that isolated tumour cells do not count as a metastasis.
- N0(i-) - No evidence of nodal metastases on histological examination, with negative immunohistochemistry
- N0(i+) - Malignant cells in regional lymph nodes, with no cluster of cells greater than 0.2 mm, detected on H&E or IHC (isolated tumour cells)
N1
- N1mi - Micrometastases - tumour deposits > 0.2 mm and ≤ 2 mm
- N1a - Metastases in 1-3 axillary nodes (levels I - II)
- N1b - Metastases in internal thoracic nodes (sentinel node biopsy ONLY, not clinically detected)
- N1c - N1a + N1b
N2
- N2a - Metastases in 4-9 axillary nodes (levels I - II)
- N2b - Clinically detected and pathological confirmed nodal metastases in internal thoracic nodes WITHOUT axillary nodes detected clinically/pathologically
N3
- N3a - Metastases in 10+ axillary nodes or metastasis to level III axillary nodes (apical or infraclavicular nodes)
- N3b - Metastases in both the axilla and internal thoracic nodes, not N1c or N2b
- N3c - Metastases in supraclavicular nodes
M Stage
M0 - No clinical or radiological evidence of metastases
cM0(i+) - No clinical or radiological evidence of metastases, BUT molecularly or microscopically detected tumour cells in the blood or other non-regional tissues
M1 - Distant metastases, either on examination, imaging or microscopy (larger than 0.2 mm)
Final Stage
| Stage | T | N | M |
|---|---|---|---|
| 0 | Tis | N0 | M0 |
| IA | T1 | N0 | M0 |
| IB | T0-1 | N1mi,, | M0 |
| IIA | T0-1 | N1 | M0 |
| T2 | N0 | M0 | |
| IIB | T2 | N1 | M0 |
| T3 | N0 | M0 | |
| IIIA | T0-3 T3 |
N2 N1-2 |
M0 |
| IIIB | T4 | N0-2 | M0 |
| IIIC | Any | N3 | M0 |
| IV | Any | Any | M1 |
