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Your Guide to the Report

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Breastcancer.org is a nonprofit organization dedicated to providing education and information on breast health and . The pathology report is used by your doctor to determine which treatments are right for you. Your Guide to the Breast Cancer  Pathology Report

A report is written each time is removed from the body to check for cancer. These are called pathology reports. Each report has the results of the studies done on the removed tissue. The information in these reports will help you and your doctors decide on the best treatment for you.

Reading your pathology report can be scary and confusing. Different labs may use different words to describe the same thing. On page 34, you’ll find an easy-to-understand word list. We hope we can help you make sense of this information so you can get the best care possible. TABLE OF CONTENTS

Wait for the Whole Picture • Waiting for test results...... 2 • How much cancer is in each ?...... 17 • Get all the information you need...... 3 • Do the cancer cells have • Parts of your pathology report...... 4 receptors?...... 18 Reading Your Pathology Report • Does the cancer have genes that • The pathology report answers affect how the cancer might questions about a breast abnormality...... 6 be treated?...... 20 •  that is not a part of • Is the breast abnormality a cancer?...... 6 your pathology report...... 25 • Is the breast cancer invasive?...... 7 • What stage is the breast cancer?...... 28 • How different are the cancer cells — Stage 0...... 28 from normal cells?...... 9 — Stage I...... 29 • How fast are the cancer cells growing?...... 10 — Stage II...... 30 • How big is the cancer?...... 12 — Stage III...... 31 • Has the whole cancer — Stage IV...... 33 been removed?...... 13 Word List...... 34 • Are there cancer cells in your lymph channels or vessels?...... 15 Key Questions...... 44 • Are there cancer cells in your Pathology Report Checklist...... 45 lymph nodes?...... 16 • How many lymph nodes Notes...... 46 are involved?...... 17 WAIT FOR THE WHOLE PICTURE

Waiting for test results Get all the information you need When you have all of the test results, When you have all the test information you and your doctor can make the you need, you and your doctor can right decisions for you. The analysis of make a final decision about your the removed tissue can lead to several treatment. Don’t focus too much on any different reports. Some tests take longer one piece of information by itself. Try to than others. Not all tests are done by look at the whole picture as you think the same lab. Most information comes about your options. within 1 to 2 weeks after , and Different labs and hospitals may you will usually have all the results use different words to describe the within a few weeks. Your doctor can let same thing. If there are words in your you know when the results come in. If pathology report that are not explained you don’t hear from your doctor, call in this booklet, don’t be afraid to ask the office. your doctor what they mean.

For more information, go to: www.breastcancer.org

EXPERT TIP: Marisa Weiss, M.D., breast cancer doctor

“The information in your pathology report three lab reports from one surgery. Together, often comes in bits and pieces. Just after the lab reports make up your pathology surgery, the cancer cells are first looked at report. Try to keep all your reports in one under the . Results from additional place, so that when you go for your treatment studies that require special techniques may evaluations, the doctors will have all the take longer. So you may have one, two, or information they need.”

2 3 WAIT FOR THE WHOLE PICTURE (continued)

Parts of your pathology report Personal information. Make sure it’s Gross description. This section describes your correct name and date of operation the pieces of tissue removed. It talks at the top of the report. about the size, weight, and color of each piece. Specimen. This section describes where the tissue samples came from. Tissue Microscopic description. This section samples could be taken from the breast, describes the way the cancer cells look from the lymph nodes under your arm under the microscope, their relationship (axilla), or both. to the normal surrounding tissue, and the size of the cancer. Clinical history. This is a short description of you and how the breast Special tests or markers. This section abnormality was found. It also describes reports the results of tests for proteins, the kind of surgery that was done. genes, and growth rate. Clinical diagnosis. This is the diagnosis Summary or final diagnosis. This section the doctors were expecting before your is the short description of all the important tissue sample was tested. findings in all of the tissue examined.

For more information, go to: www.breastcancer.org

4 5 READING YOUR PATHOLOGY REPORT

The pathology report answers questions may grow into the normal tissue around about a breast abnormality them. Cancer cells may also spread beyond the breast. Breast tissue can develop abnormalities that are sometimes cancerous. Usually The abnormal lump or spot may be found breast cancer begins either in the cells using or other testing of the lobules, which are milk-producing methods. A procedure called a glands, or the ducts, the passages that removes a piece of tissue from the lump or drain milk from the lobules to the . spot to find out if cancer cells are present. Breast have many characteristics The pathology report will tell you what that help determine the best treatment. kinds of cells are present.

Is the breast abnormality a cancer? Is the breast cancer invasive? A lump or spot in the breast can be made If breast cancer is found, it’s important of normal cells or cancer cells. There can to know whether the cancer has spread also be cells that fall somewhere between outside the milk ducts or lobules of the normal and cancerous (“atypical” cells). breast where it started. Cancer cells are cells that grow in an Non-invasive cancers stay within the milk uncontrolled way. They may stay in the ducts or milk lobules in the breast. They place where they started to grow, or they do not grow into or invade normal tissues This is what the inside within or beyond the breast. Non-invasive of a breast looks like. cancers are sometimes called in situ or pre-cancers. The real size of a normal If the cancer has grown into normal or lobule rib cage tissues, it is called invasive. Most breast is smaller chest wall than this cancers are invasive. Sometimes cancer . cells spread to other parts of the body through the blood or lymph system. When muscle lobule cancer cells spread to other parts of the duct body, it is called . In some cases, a breast cancer may be both invasive and non-invasive. nipple

non- This is what normal cells invasive invasive inside a milk duct look cells cells like under a microscope.

6 7 READING YOUR PATHOLOGY REPORT (continued)

You may see these descriptions of the How different are the cancer cells type of cancer cells in your report: from normal cells? DCIS (Ductal In Situ). This is a cancer that is non-invasive. It stays Grade is how different the cancer cells inside the milk ducts. are from normal cells. Experts compare the appearance of the cancer cells to NOTE: There are subtypes of DCIS. You’ll normal breast cells. Based on these find their names in the word list that begins comparisons, they give a grade to the on page 34 of this booklet. cancer. Grade is different from stage LCIS ( In Situ). This (see page 28 for information about is a tumor that is an overgrowth of cells stage). that stay inside the milk-making part There are three cancer grades: of the breast (called lobules). LCIS is not a true cancer. It’s a warning sign Grade 1 (low grade or well of an increased risk for developing an differentiated). Grade 1 cancer cells look invasive cancer in the future in either a little bit different from normal cells. breast. They are usually slow-growing. IDC (Invasive Ductal Carcinoma). This is Grade 2 (intermediate/moderate grade a cancer that begins in the milk duct but or moderately differentiated). Grade 2 has grown into the surrounding normal cancer cells do not look like normal cells. tissue inside the breast. This is the most They are growing a little faster than common kind of breast cancer. normal. ILC (Invasive Lobular Carcinoma). This Grade 3 (high grade or poorly is a cancer that starts inside the milk- differentiated). Grade 3 cancer cells look making glands (called lobules), but very different from normal cells. They are grows into the surrounding normal fast-growing. tissue inside the breast.

NOTE: There are other, less common types of invasive breast cancer. You’ll find their names in the word list beginning on page 34 of this booklet. For more information, go to: www.breastcancer.org

MY REPORT SAYS:

The type of cancer I have is______The cancer is: (check one) ______. j Grade 1 j Grade 2 j Grade 3 8 9 READING YOUR PATHOLOGY REPORT (continued)

How fast are the cancer cells In breast cancer, a result of less than growing? 10% is considered low, 10-20% is intermediate/borderline, and more Your pathology report may include than 20% is considered high. information about the rate of cell If you have an Oncotype DX test growth—the proportion of cancer cells done on the cancer to estimate your within the tumor that are growing and recurrence risk, checking Ki-67 levels is dividing to form new cancer cells. A included as part of the testing. higher percentage suggests a faster- growing, more aggressive cancer, rather • S-phase fraction. The S-phase fraction than a slower, less aggressive cancer. number tells you what percentage of cells in the tissue sample are in Tests that can measure the rate of cell the process of copying their genetic growth include: information (DNA). This S-phase, short • Ki-67. Ki-67 is a protein in cells that for “synthesis phase,” happens just increases as they prepare to divide before a cell divides into two new cells. into new cells. A staining process can measure the percentage of tumor In breast cancer, a result of less than cells that are positive for Ki-67. The 6% is considered low, 6-10% is more positive cells there are, the more intermediate/borderline, and more quickly they are dividing and forming than 10% is considered high. new cells.

For more information, go to: www.breastcancer.org

MY REPORT SAYS:

The rate of cancer growth is: (check one) Test used: (check one) j Low j Intermediate/borderline j High j Ki-67 test j S-phase fraction test 10 11 READING YOUR PATHOLOGY REPORT (continued)

How big is the cancer? Has the whole cancer been removed? Doctors measure cancers in centimeters When surgery is done to remove the (cm). The size of the cancer is one of the whole cancer, the surgeon tries to take factors that determines the stage and out all of the cancer with an extra area, treatment of the breast cancer. or margin, of normal tissue around it. This is to be sure that all of the cancer Size doesn’t tell the whole story. All of is removed. the cancer’s characteristics are important. A small cancer can be very fast-growing The outer edge of the tissue removed while a larger cancer may be slow-growing, is called the margin of resection. It is or it could be the other way around. looked at very carefully to see if it is clear of cancer cells. Tumor size: 1 cm The pathologist also measures the distance between the cancer cells and the margin.

3 cm

5 cm

= 2 inches

For more information, go to: www.breastcancer.org

MY REPORT SAYS:

The size of the cancer is ______centimeters.

12 13 READING YOUR PATHOLOGY REPORT (continued)

Margins around a cancer are described Are there cancer cells in your lymph in three ways: channels or blood vessels? Negative. No cancer cells can be seen The breast has a network of lymph at the outer edge. Usually, no more channels and blood vessels that drain surgery is needed. fluid and blood from your breast tissue Positive. Cancer cells come right out back into your body’s circulation. These to the edge of the tissue. More surgery pathways remove used blood and waste is usually needed to remove any products. remaining cancer cells. There is an increased risk of cancer Close. Cancer cells are close to the edge coming back when cancer cells are found of the tissue, but not right at the edge. in the fluid channels of the breast. In More surgery may be needed. these cases, your doctor may customize Negative Positive your treatment to reduce this risk. If lymphatic or blood vessel (vascular) is found, your pathology report will say present. If there is no invasion, the report will say absent.

normal normal NOTE: Lymphatic or vascular invasion is the edge tissue the edge tissue different from lymph node involvement. cancer cancer cells cells This is a picture of cancer cells that have NOTE: What is called negative (or clean or spread through the wall of the milk duct clear) margins can be different from hospital and into the nearby lymph channels. to hospital. In some hospitals, doctors want at least 2 millimeters (mm) of normal tissue lymphatic channel between the edge of the cancer and the outer edge of the tissue. In other places, breast tissue cancer cells just one healthy cell is called a negative margin. 1 cm normal duct cells

blood vessel wall of milk duct 2 mm 1 inch MY REPORT SAYS:

The margins are: (check one) Lymphatic or vascular invasion is: (check one) j Negative j Positive j Close j Present j Absent 14 15 READING YOUR PATHOLOGY REPORT (continued)

Are there cancer cells in your How many lymph nodes lymph nodes? are involved? Your doctor will examine your lymph The more lymph nodes that contain nodes to see if they contain cancer. cancer cells, the more serious the Having cancer cells in the lymph nodes cancer might be. So doctors use the under your arm is associated with an number of involved lymph nodes to increased risk of the cancer spreading. help make treatment decisions. Lymph nodes are filters along the lymph Doctors also look at the amount of fluid channels. Lymph fluid leaves the cancer in the lymph nodes. breast and eventually goes back into the bloodstream. The lymph nodes try to How much cancer is in each catch and trap cancer cells before they lymph node? reach other parts of the body. You may see these words describing When lymph nodes are free, or clear, how much cancer is in each lymph node: of cancer, the test results are called Microscopic. Only a few cancer cells are negative. If lymph nodes have some in the node. A microscope is needed to cancer cells in them, they are called find them. positive. Gross. There is a lot of cancer in the Lymph node areas adjacent to breast area node. You can see or feel the cancer A Pectoralis major without a microscope. muscle B Axillary lymph Extracapsular extension. Cancer has nodes: level I spread outside the wall of the node. C Axillary lymph nodes: level II D Axillary lymph nodes: level III E Supraclavicular lymph nodes F Internal mammary lymph nodes For more information, go to: www.breastcancer.org MY REPORT SAYS:

The lymph nodes are: (check one) If positive: j Positive j Negative The number of involved nodes is ______. 16 17 READING YOUR PATHOLOGY REPORT (continued)

Do the cancer cells have 1. The number of cells that have receptors out of 100 cells tested.

hormone receptors? You will see a number between 0% Hormone receptors are like ears on and (none have receptors) and 100% (all in breast cells that listen to signals from have receptors). . These hormone signals tell 2. An Allred score between 0 and 8. breast cells that have the receptors to This scoring system is named for the grow. doctor who developed it. The system A cancer is called ER-positive if it has looks at what percentage of cells receptors for the hormone . It’s test positive for hormone receptors, called PR-positive if it has receptors for along with how well the receptors the hormone . Breast cells show up after staining (this is called that do not have receptors are negative “intensity”). This information is then for these hormones. combined to score the sample on a scale from 0 to 8. The higher the Breast cancers that are ER-positive, score, the more receptors were found PR-positive, or both tend to respond to and the easier they were to see in the hormonal therapy. Hormonal therapy sample. is that reduces the amount 3. The word “positive” or “negative.” of estrogen in your body or that blocks estrogen from the receptors. NOTE: Even if your report just says “positive” or “negative,” ask your doctor If the cancer has no hormone receptors, or lab to give you the number of cells there are still treatments available. (percentage) that have receptors. This Hormone receptors are proteins. Like all is important because sometimes a low proteins, their production is controlled number may be called negative. But even cancers with low numbers of hormone by genes. To learn more about tests for receptors may respond to hormonal various genes, please see page 20. therapy. And a high positive number is You will see the results of your hormone important to know because it predicts a particularly good response to hormonal test written in one of these therapy. three ways: For more information, go to: www.breastcancer.org MY REPORT SAYS: Hormone receptors are: j ER-positive ____% (1%-100%) j ER-negative j PR-positive ____% (1%-100%) j PR-negative or circle: Allred score: 0 1 2 3 4 5 6 7 8 or circle: Allred score: 0 1 2 3 4 5 6 7 8 18 19 READING YOUR PATHOLOGY REPORT (continued)

Does the cancer have genes that HER2 status. Your pathology report affect how the cancer might be usually includes the cancer’s HER2 status. The HER2 gene is responsible for treated? making HER2 proteins. These proteins Genes contain the recipes for the are receptors on breast cells. Under various proteins a cell needs to stay normal circumstances, HER2 receptors healthy and function normally. Some help control how a breast cell grows, genes and the proteins they make divides, and repairs itself. But in about can influence how a breast cancer 25% of breast cancers, the HER2 gene behaves and how it might respond to can become abnormal and make too a specific treatment. Cancer cells from many copies of itself (amplification of a tissue sample can be tested to see the HER2 gene). Amplified HER2 genes which genes are normal and which are command breast cells to make too abnormal. The proteins they make can many receptors (overexpression of the also be tested. HER2 protein). When this happens, the If the genetic recipe contains a mistake, overexpressed HER2 receptors shout at the report will say “genetic mutation” (rather than talk to) the breast cells to or “genetic abnormality.” An example grow and divide in an uncontrolled way. is one of the inherited breast cancer This can lead to the development of gene abnormalities, called BRCA1 or breast cancer. BRCA2. Testing for BRCA1 and BRCA2 Breast cancers that have amplified HER2 is not part of the standard pathology genes or that overexpress the HER2 workup. (Please see page 25 for more protein are described in the pathology information on these abnormalities.) report as being HER2-positive. HER2- If the genetic recipe repeats the same positive breast cancers tend to grow instruction over and over again, the faster and are more likely to spread and report will say “gene amplification.” come back when compared with HER2- Genetic amplification happens when negative breast cancers. But HER2- a genetic recipe’s repeated instruction positive breast cancers can respond to causes the gene to make too many targeted treatments that are designed to copies of itself. work against HER2-positive cancer cells. If the genetic recipe mistake (abnormality) or repeated instruction For more information, go to: (amplification) calls for too much protein www.breastcancer.org to be made, the report will say that there is overexpression of that protein.

20 21 READING YOUR PATHOLOGY REPORT (continued)

There are four tests for HER2: 4. Inform HER2 Dual ISH test (In Situ 1. IHC test (ImmunoHistoChemistry): Hybridization): • The IHC test shows whether there is • The Inform HER2 Dual ISH test too much HER2-receptor protein in shows whether there are too many the cancer cells. copies of the HER2 gene in the • The results of the IHC test can be cancer cells. 0 (negative), 1+ (also negative), 2+ • The results of the Inform HER2 (borderline), or 3+ (positive; the Dual ISH test can be positive (extra HER2 protein is overexpressed). copies—amplified) or negative (normal number of copies—not 2. FISH test (Fluorescence In Situ amplified). Hybridization): Find out which test for HER2 you had. • The FISH test shows whether there This is important. Only cancers that test are too many copies of the HER2 IHC 3+, FISH positive, SPoT-Light HER2 gene in the cancer cells. CISH positive, or Inform HER2 Dual ISH • The results of the FISH test can be positive respond to therapy that works positive (extra HER2 gene copies— against HER2-positive breast cancers. amplified) or negative (normal An IHC 2+ test result is called borderline. number of HER2 gene copies—not Research has shown that some HER2 amplified). status test results may be wrong. 3. SPoT-Light HER2 CISH test This is probably because different (Subtraction Probe Technology labs have different classification rules. Chromogenic In Situ Hybridization): Each pathologist also may use slightly different criteria. This usually happens • The SPoT-Light test shows whether when test results are borderline (IHC there are too many copies of the 2+). If you have a 2+ result, you can HER2 gene in the cancer cells. and should ask to also have the tissue • The results of the SPoT-Light test tested with the FISH test. If your results can be positive (extra copies— are negative, you may want to ask your amplified) or negative (normal doctor if another HER2 test makes sense number of copies—not amplified). for you. For more information, go to: www.breastcancer.org MY REPORT SAYS:

HER2 status is: (check one) Test used: (check one) j IHC j FISH j Positive j Negative j Borderline j SPoT-Light HER2 CISH j Inform HER2 Dual ISH 22 23 READING YOUR PATHOLOGY REPORT (continued)

EGFR status. The EGFR gene, much like Genetic testing that is not a part of the HER2 gene, can be overexpressed in some breast cancer cells and influence your pathology report how the cancer cells behave. Your Inherited cases of breast cancer are pathology report may also contain likely associated with abnormal genes. information about EGFR overexpression. Two of the most common are abnormal Genomic assays. Unlike individual versions of BRCA1 (BReast CAncer gene gene testing, such as testing for HER2, 1) and BRCA2 (BReast CAncer gene 2). genomic assays analyze the activity of According to the National Cancer a group of normal and abnormal genes Institute, women with an abnormal that can increase the risk of breast BRCA1 or BRCA2 gene have about a cancer coming back after treatment. This 60% risk of being diagnosed with breast analysis can help decide if a person is cancer during their lifetimes (compared likely to benefit from to to about 12% for women overall). Their reduce the risk of the cancer coming risk of is also increased. back. A number of genomic assays for Abnormal BRCA1 or BRCA2 genes are breast cancer are currently available, found in 5% to 10% of all breast cancer including Oncotype DX, MammaPrint, cases in the United States. and Mammostrat. Changes in other genes are also If the breast cancer is early-stage and associated with breast cancer, though hormone-receptor-positive, you and they are less common and don’t seem your doctor may decide that a genomic to increase risk as much as abnormal assay is appropriate for your situation. The results of your genomic assay are BRCA1 and BRCA2 genes. Although reported separately from your abnormal BRCA1 and BRCA2 genes are pathology report. The test results will considered rare, the following genes indicate the likelihood of the cancer are considered rarer and haven’t been coming back based on the overall studied as much as the BRCA genes: pattern of gene activity found in the • ATM gene. Inheriting one abnormal breast cancer cells. Your doctor can use ATM gene has been linked to an this information to help decide whether increased rate of breast cancer in some chemotherapy to reduce the risk of families because the abnormal gene breast cancer coming back makes sense stops the cells from repairing damaged in your overall treatment plan. DNA. The Oncotype DX test also is used to estimate recurrence risk of DCIS and/ For more information, go to: or the risk of a new invasive cancer www.breastcancer.org developing in the same breast, and how likely a person is to benefit from therapy after DCIS surgery.

24 25 READING YOUR PATHOLOGY REPORT (continued)

•  gene. Inheriting an abnormal Finding out whether you have an p53 gene (also called the TP53 gene) inherited abnormal gene requires causes Li-Fraumeni syndrome, a special tests, and the results are disorder that causes people to develop separate from the results in your soft tissue cancers at a young age. pathology report. If your doctor is • CHEK2 gene. Li-Fraumeni syndrome concerned that you and your immediate also can be caused by an abnormal relatives may have inherited abnormal CHEK2 gene; even when it doesn’t BRCA1 or BRCA2 gene, he or she cause Li-Fraumeni syndrome, an may recommend that you and other abnormal CHEK2 gene can double family members be tested. BRCA1 and breast cancer risk. BRCA2 tests are done using a blood or saliva sample, not a tissue sample. • PTEN gene. An abnormal PTEN gene Your doctor or genetic counselor also causes , a rare may order testing for an abnormal disorder that causes a higher risk of ATM, p53, CHEK2, PTEN, or CDH1 gene both benign and cancerous breast if it’s determined from your personal tumors, as well as growths in the or family history that these tests are digestive tract, thyroid, uterus, and needed. . • CDH1 gene. Women with an abnormal CDH1 gene have a higher risk of invasive lobular breast cancer.

For more information, go to: www.breastcancer.org

26 27 READING YOUR PATHOLOGY REPORT (continued)

What stage is the breast cancer? Stage I Cancer stage is based on the size of the Stage I is divided into subcategories cancer, whether the cancer is invasive known as IA and IB. or non-invasive, whether lymph nodes Stage IA describes invasive breast are involved, and whether the cancer cancer (cancer cells are breaking has spread to other places beyond the through to or invading normal breast. Many of the cancer traits you surrounding breast tissue) in which: reviewed in this booklet are not included • the tumor measures up to 2 centimeters in staging. AND The purpose of the staging system is to • the cancer has not spread outside the help organize the different factors and breast; no lymph nodes are involved some of the personality features of the Stage IB describes invasive breast cancer into categories in order to: cancer in which: • best understand your prognosis (the • there is no tumor in the breast; instead, most likely outcome of the ) small groups of cancer cells—larger • guide treatment decisions (together than 0.2 millimeter but not larger than 2 millimeters—are found in the lymph with other parts of your pathology nodes OR report) • there is a tumor in the breast that • provide a common way to describe is no larger than 2 centimeters, and the breast cancer so that results of there are small groups of cancer your treatment can be compared and cells—larger than 0.2 millimeter but understood not larger than 2 millimeters—in the lymph nodes Stage 0 Microscopic invasion is also possible Stage 0 is used to describe non-invasive in stage I breast cancer. In microscopic breast cancers, such as ductal carcinoma invasion, the cancer cells have only just begun to invade the tissue outside the in situ (DCIS). In stage 0, there is no lining of the duct or lobule. To qualify evidence of cancer cells or non-cancerous as microscopic invasion, the cells that abnormal cells breaking out of the part have begun to invade the tissue cannot of the breast in which they started, or measure more than 1 millimeter. getting through to or invading neighboring normal tissue. For more information, go to: www.breastcancer.org

28 29 READING YOUR PATHOLOGY REPORT (continued)

Stage II Stage III Stage II is divided into subcategories Stage III is divided into subcategories known as IIA and IIB. known as IIIA, IIIB, and IIIC. Stage IIA describes invasive breast Stage IIIA describes invasive breast cancer in which: cancer in which either: • no tumor can be found in the breast, • no tumor is found in the breast or the but cancer (larger than 2 millimeters) tumor may be any size; cancer is found is found in 1 to 3 in 4 to 9 axillary lymph nodes or in (the lymph nodes under the arm) or in the lymph nodes near the breastbone the lymph nodes near the breastbone (found during imaging tests or a (found during a sentinel node biopsy) physical exam) OR OR • the tumor is larger than 5 centimeters; • the tumor measures 2 centimeters or small groups of breast cancer cells smaller and has spread to the axillary (larger than 0.2 millimeter but not lymph nodes OR larger than 2 millimeters) are found in • the tumor is larger than 2 centimeters the lymph nodes OR but not larger than 5 centimeters and • the tumor is larger than 5 centimeters; has not spread to the axillary lymph cancer has spread to 1 to 3 axillary nodes lymph nodes or to the lymph nodes Stage IIB describes invasive breast near the breastbone (found during a cancer in which: sentinel ) • the tumor is larger than 2 centimeters Stage IIIB describes invasive breast but no larger than 5 centimeters; small cancer in which: groups of breast cancer cells—larger • the tumor may be any size and has than 0.2 millimeter but not larger than spread to the chest wall and/or skin of 2 millimeters—are found in the lymph nodes OR the breast and caused swelling or an AND • the tumor is larger than 2 centimeters but no larger than 5 centimeters; • may have spread to up to 9 axillary cancer has spread to 1 to 3 axillary lymph nodes OR lymph nodes or to lymph nodes near • may have spread to lymph nodes near the breastbone that were found during the breastbone a sentinel node biopsy OR • the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

30 31 READING YOUR PATHOLOGY REPORT (continued)

Stage III (continued) Stage IV Inflammatory breast cancer is Stage IV describes invasive breast considered at least stage IIIB. Typical cancer in which: features of inflammatory breast cancer • the cancer has spread beyond the include the following: breast and nearby lymph nodes to • a substantial portion of the breast skin other organs of the body, such as the is reddened , distant lymph nodes or skin, • the breast feels warm and may be , , or swollen The words used to describe stage IV • cancer cells have spread to the lymph breast cancer are “advanced” and nodes and may be found in the skin “metastatic.” Cancer may be stage IV at first diagnosis, or it can be a recurrence Stage IIIC describes invasive breast of a previous breast cancer that has cancer in which: spread to other parts of the body. • the cancer has spread to 10 or more axillary lymph nodes OR • the cancer has spread to lymph nodes above or below the collarbone OR • the cancer has spread to axillary lymph nodes or to lymph nodes near the breastbone

For more information, go to: www.breastcancer.org

MY REPORT SAYS:

The cancer is stage: (check one) j Stage IIA j Stage IIB j Stage IIIA j Stage 0 j Stage IA j Stage IB j Stage IIIB j Stage IIIC j Stage IV 32 33 WORD LIST

Abnormal cells: Cells that do not look or BRCA2: An abnormal gene, known as act like the healthy cells of the body. BReast CAncer gene 2, associated with a Aggressive cancer cells: Cells that are higher risk of developing breast cancer. fast-growing and have a tendency to Clean margins: Removed breast tissue spread beyond the area where they around the tumor in which the outer started. edge is free of cancer cells. Also called Atypical ductal : Abnormal “negative margins.” cells that have accumulated in a breast Close margins: Removed breast tissue duct. The cells have increased in number around the tumor in which cancer cells and fill almost the entire duct. The cells come near the outer edge. can keep changing until they become Colloid (mucinous) carcinoma of the DCIS. Atypical ductal hyperplasia can breast: A rare type of invasive breast increase the risk of a future breast cancer that contains small pools of cancer. mucous material. Atypical lobular hyperplasia: Abnormal Comedo DCIS: A type of non-invasive cells that have accumulated in a cancer that tends to grow quickly. breast lobule. The cells have increased Comedo refers to areas of dead cancer in number and fill almost the entire cells that build up inside the tumor—a lobule. It’s possible for the cells to sign that the cancer cells are growing keep changing until they become so quickly that some of the cells are not LCIS. Atypical lobular hyperplasia can getting enough nourishment. increase the risk of a future breast Comedonecrosis: Clumps of dead cancer. cancer cells, often seen in high-grade Axillary lymph nodes: Lymph nodes DCIS. The cells are so crowded that under your arms. some of them do not get enough Basal-like breast cancer: Basal-like nourishment and die. is one of the four main molecular Cribriform carcinoma of the breast: A subtypes of breast cancer. Basal-like less common type of invasive breast breast cancer is hormone-receptor- cancer that invades the connective negative and HER2-negative. Also called tissues of the breast and features holes triple-negative breast cancer. between the cancer cells (like the holes Benign: Not cancerous or precancerous. in Swiss cheese). Biopsy: An operation to remove tissue Cribriform DCIS: A type of non-invasive to check whether it’s cancer or not. breast cancer that usually grows slowly. BRCA1: An abnormal gene, known as Cribriform DCIS features gaps between BReast CAncer gene 1, associated with a cancer cells in the affected ducts (like higher risk of developing breast cancer. the pattern of holes in Swiss cheese).

34 35 WORD LIST (continued)

Ductal (DCIS): An Gross lymph node involvement: A uncontrolled growth of breast cells situation in which many cancer cells are within the milk duct without invasion found in a lymph node. into the normal surrounding breast HER2 (Human Epidermal tissue. Receptor 2): A gene that helps control EGFR gene: A gene that controls how the growth and repair of cells. quickly cells divide. Also called HER1. HER2-enriched: HER2-enriched is one EGFR-negative: A breast cancer with a of the four main molecular subtypes normal number of the EGFR gene. of breast cancer. HER2-enriched breast EGRF-positive: A breast cancer with too cancer is hormone-receptor-negative many copies of the EGFR gene. and HER2-positive. ER-negative: A cancer that does not HER2 gene amplification: A situation have estrogen receptors. that arises when a HER2 gene doesn’t ER-positive: A cancer that has estrogen work correctly and makes too many receptors. copies of itself. Estrogen: The major female sex HER2-negative: A breast cancer with hormone. Estrogen can cause some a normal number of HER2 genes and cancers to grow. protein receptors. Extracapsular extension: When cancer HER2-positive: A breast cancer with has spread outside the wall of a lymph HER2 gene amplification or HER2 node. protein overexpression. HER2-positive Fibrocystic changes: Benign changes breast cancers tend to grow faster and in the breast, such as large amounts of are more likely to spread and come rubbery, firm (“fibrous”) tissue or fluid- back compared to HER2-negative breast filled . cancers. FISH (Fluorescence In Situ Hybridization) HER2 protein overexpression: When the test: A test for multiple genes, including HER2 gene makes too many copies of the HER2 gene. itself, and those extra HER2 genes tell breast cells to make too many HER2 Gene: The code material for a cell to receptors. make a single protein. Proteins perform different functions for the cell including HER2 receptors: Proteins made by the growth and repair. HER2 gene that receive signals that stimulate cells to grow and multiply. Genomic assay: A test that analyzes the activity of a group of genes. Hormone receptors: Proteins on and Grade: How different the cancer cells in cells that respond to signals from look from normal cells as well as how hormones. quickly the cells are growing.

36 37 WORD LIST (continued)

IHC (ImmunoHistoChemistry) test: A Local recurrence: A breast cancer that test used to measure proteins, including comes back in the breast area where it the HER2 protein. was originally diagnosed. In situ: A cancer within the part of the Locoregional recurrence: A breast breast where it started, such as in the cancer that comes back in the lymph ducts, without signs of spread. nodes in the armpit or collarbone area Infiltrating: A cancer that has spread near where the cancer was originally beyond the place where it started. Also diagnosed. Sometimes referred to as called “invasive.” “regional” recurrence. Inflammatory Breast Cancer (IBC): A Luminal A breast cancer: Luminal A rare and aggressive form of breast breast cancer is one of the four main cancer that starts with reddening, molecular subtypes of breast cancer. swelling, and warmth of the breast, with Luminal A breast cancer is hormone- symptoms worsening within days or receptor-positive (either estrogen- and/ hours. IBC is considered at least stage or progesterone-positive) and HER2- IIIB. negative. Inform HER2 Dual ISH test: A test used Luminal B breast cancer: Luminal B to figure out whether breast cancer cells breast cancer is one of the four main are HER2-positive. molecular subtypes of breast cancer. Invasive: A cancer that has spread Luminal B breast cancer is hormone- beyond the place where it started. Also receptor-positive (either estrogen- and/ called “infiltrating.” or progesterone-receptor-positive) and Invasive Ductal Carcinoma (IDC): A HER2-positive. cancer that started in the milk duct but Lymph channels: Vessels that drain has grown into the normal breast tissue clear, cell-cleansing fluid (“lymph”) around it. away from tissues. Invasive Lobular Carcinoma (ILC): A Lymph nodes: cancer that started in the milk lobules Filters along the lymph and has grown into the normal breast fluid channels; they can catch and trap tissue around it. cancer cells before they reach other parts of the body. Ki-67 test: A test that shows how fast cancer is growing. Lymph system: A network of vessels and nodes that creates and drains clear, Lobular Carcinoma In Situ (LCIS): Cells that are not normal but stay inside cell-cleansing fluid (“lymph”) from the the milk-making parts of the breast body. The lymph system is an important (lobules). LCIS isn’t a true cancer, but part of the body’s immune system. a warning sign of an increased risk for Lymphatic invasion: When cancer cells developing an invasive cancer in the are found in the lymph channels. future in either breast.

38 39 WORD LIST (continued)

MammaPrint: A test that analyzes 70 Milk lobules: Milk-making glands in the genes from an early-stage breast cancer breast. tissue sample to find out whether breast Moderately differentiated: Cancer cells cancer has a low or high risk of coming that don’t look like normal cells. They back within 10 years after diagnosis. grow a little faster than normal. Also Mammostrat: A test that measures called “grade 2.” the levels of five genes in early-stage, Mucinous (colloid) carcinoma of the hormone-receptor-positive breast breast: A rare type of invasive cancer that cancer cells. A risk index score is then contains small pools of mucous material. calculated; the higher the score, the Negative margins: Removed breast more likely the cancer is to come back tissue around the tumor in which the (recur). outer edge is free of cancer cells. Also Margin: The layer of healthy breast called “clean margins.” tissue around the cancer that was Non-invasive: A cancer that stays inside removed during surgery. the part of the breast where it started. Medullary carcinoma of the breast: A Oncotype DX: A test that provides rare type of invasive cancer that usually information on how likely the breast presents with a soft, fleshy tumor that cancer is to return and whether you are resembles a part of the brain called the likely to benefit from chemotherapy. medulla. Medullary carcinoma of the Oncotype DX can also determine breast is usually hormone-receptor- whether someone with DCIS can benefit negative and HER2-negative. from . : The time when a Papillary carcinoma of the breast: A completely stops getting her period rare type of invasive breast cancer (menstruating). that is made up of small, finger-like Metastatic: Breast cancer that has projections. spread to other parts of the body, such Papillary DCIS: A type of non-invasive as the bones or brain. breast cancer that does not spread and Microscopic invasion: A situation in tends to grow slowly. Papillary DCIS which cancer cells have just started to features cancer cells arranged in a invade the tissue outside the lining of a finger-like pattern within the ducts. duct or lobule. Pathologist: A doctor who looks at Microscopic lymph node involvement: tissue under a microscope to see if it’s When only a small number of cancer normal or affected by disease. cells are found in a lymph node. Pathology report: The written results Milk ducts: Tiny tubes in the breast that of each test done on tissue after it has carry milk from the lobules to the nipple. been removed from the body during biopsy, , or .

40 41 WORD LIST (continued)

Perimenopause: The 1- to 3-year period Sclerosing adenosis: A benign breast of hormonal flux before periods stop condition in which enlarged lobules completely. form breast lumps. Poorly differentiated: Cancer cells that : The first lymph look very different from normal cells. node or nodes to which cancer cells are They are fast-growing. Also called likely to spread from a tumor. “grade 3.” Solid DCIS: A type of non-invasive Positive margins: A situation in which breast cancer; it tends to grow slowly. cancer cells come up to the outer edge Solid DCIS cancer cells completely fill of the breast tissue that was removed the affected breast ducts. during surgery. This suggests that more SPoT-Light HER2 CISH test: A test used cancer cells were left behind in the to count the number of copies of the body. HER2 gene. PR-negative: A cancer that does not Staging: A system doctors use to have progesterone receptors. classify a breast cancer according to PR-positive: A cancer that has how advanced it is. progesterone receptors. Triple-negative breast cancer: Breast Pre-cancerous: An overgrowth of cancer that tests negative for estrogen abnormal cells that shows no signs receptors, progesterone receptors, and of invasion. Pre-cancerous cells are a HER2. Triple-negative breast cancer warning sign of possibly developing tends to be more aggressive than other cancer in the future. types of breast cancer. Progesterone: A female sex hormone. Tubular carcinoma of the breast: A rare Progesterone can cause some cancers type of invasive breast cancer that is to grow. made up of tube-shaped cells and tends Prognosis: The most likely outcome of to grow slowly. a disease. Vascular invasion: When cancer cells are Recurrence: When a cancer comes back. found in the blood vessels. Regional recurrence: A breast cancer Well differentiated: Cancer cells that that comes back in the lymph nodes look a little bit different from normal in the armpit or collarbone area near cells. They are usually slow-growing. where the cancer was originally Also called “grade 1.” diagnosed. Sometimes referred to as “locoregional”recurrence. S-phase fraction test: A test that shows For more information, go to: how fast a cancer is growing. www.breastcancer.org

42 43 PATHOLOGY KEY QUESTIONS REPORT CHECKLIST

With your doctor’s help, it’s important This checklist can help you keep the that you understand the answers to the important results from all your pathology questions below: reports together in one place. With your doctor’s help, fill in the answers below. 1. Is this breast cancer invasive, Then take this booklet with you when you non-invasive, or both invasive and visit your other doctors, so they have the non-invasive? information they need. 2.  Is this a slow-growing or a fast-growing My pathology reports show the following cancer features: breast cancer? 1. Invasive or non-invasive: 3.  Are the margins negative, close, or j invasive j non-invasive positive? j both invasive and non-invasive 2. Size: ______centimeters (cm) 4. Are there any cancer cells present in lymph channels or blood vessels? 3. Grade: j grade 1 j grade 2 j grade 3 4. Lymphatic or vascular involvement: 5.  What do the hormone receptor tests j present j absent show? Can I take a medicine that lowers 5. Margins of resection: or blocks the effects of estrogen? j negative j close j positive 6. Which of these HER2 tests was 6. Hormone receptors: performed on the tissue? estrogen receptors: j positive ______% (0%-100%) j negative • IHC (ImmunoHistoChemistry) test or circle: Allred score 0 1 2 3 4 5 6 7 8 • FISH (Fluorescence In Situ progesterone receptors: Hybridization) test j positive ______% (0%-100%) j negative • SPoT-Light HER2 CISH (Subtraction or circle: Allred score 0 1 2 3 4 5 6 7 8 Probe Technology Chromogenic In Situ 7. HER2 status based on one or more of these Hybridization) test tests: IHC (ImmunoHistoChemistry) test: j positive j negative j borderline • Inform HER2 Dual ISH (Inform Dual In Situ Hybridization) test FISH (Fluorescence In Situ Hybridization) test: j positive (amplified) j negative (not amplified) 7. Is the HER2 test positive, negative, or SPoT-Light HER2 CISH (Subtraction Probe borderline? Technology Chromogenic In Situ Hybridization) test: 8.  Are any lymph nodes involved j positive (amplified) j negative (not amplified) with this cancer? If so, how many? Inform HER2 Dual ISH (Inform Dual In Situ Hybridization) test: 9. What other lab tests were done on the j positive (amplified) j negative (not amplified) cancer tissue? What did they show? 8. Lymph node status: 10. Is any further surgery recommended j positive (cancer found in lymph node[s]) based on these results? number of lymph nodes involved: ______j negative (no cancer in lymph nodes) 11. Which treatments are most likely to work 9. Oncotype DX, MammaPrint, or Mammostrat for this specific cancer? test results: Recurrence score: ______10-year recurrence risk: ______

44 45 NOTES

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