Breast cancer is the most common cancer among women, and although the majority are diagnosed with early-stage disease, some will experience a recurrence.
Jennifer K. Plichta, M.D., M.S., FACS, CGRA
President, National Consortium of Breast Centers; Director, Breast Risk Assessment Clinic, Duke Cancer Institute; Co-Director, Clinical Cancer Genetics, Duke Cancer Institute; Associate Professor, Duke Departments of Surgery & Population Health Sciences
Kristie A. Bobolis, M.D., BHCN, CGRA
Certification Board President, National Consortium of Breast Centers; Medical Director, Breast Cancer Program, Sutter Roseville Medical Center
The term “early breast cancer” can include a variety of presentations at diagnosis, although it is often referring primarily to patients with stage I or stage II breast cancer, based on the American Joint Committee on Cancer’s (AJCC) staging guidelines, which were last published in 2016 and updates are underway.1 While breast cancer staging was previously based solely on tumor size, axillary nodal status, and distant metastasis (also referred to as “TNM staging” or “anatomic staging”), it now includes additional prognostic markers, such as the hormone receptors (estrogen and progesterone receptors, ER/PR), human-epidermal-growth-factor-receptor-2 (HER2), histologic tumor grade, and genomic profiles. Thus, the latest stage groups are collectively termed “prognostic stages.”
Given the changes in systemic therapies over the years, the latest AJCC staging guidelines reflect contemporary treatment strategies for patients with breast cancer, which are increasingly guided by tumor biology, in addition to the extent of the disease. Furthermore, these updates in staging further refined prognostic estimates for the assigned stage groups, and a recent study noted that more than 35% of patients had a change in their stage based on these guidelines.2 In a large validation study of 50,000 patients in the California Cancer Registry, the 5-year disease-specific survival was noted to be 97-99% for patients with stage I disease and 93-94% for those with stage II breast cancer, thus demonstrating excellent outcomes for the vast majority of patients with early-stage breast cancer.3
Determining the risk of recurrence
Importantly, there are several prognostic assays based on gene expression that are currently being used in clinical practice to help determine the risk of recurrence and potential benefit of adjuvant systemic therapy (such as chemotherapy), although only one of them is included in the AJCC staging guidelines. The National Comprehensive Cancer Network (NCCN) highlights five specific assays (Breast Cancer Index, EndoPredict, Mammaprint, Oncotype Dx, and Prosigna) that provide prognostic information and are based on high-level evidence and/or uniform NCCN consensus (≥85% support of the NCCN panel).4 These assays are most commonly performed on tissue removed during surgery but may also be performed on needle biopsy specimens. These test results help doctors and patients develop personalized treatment strategies based on the identified level of recurrence risk.
However, given the low risk of mortality with early-stage breast cancer, the latest guidelines from the NCCN recommend a history and physical exam every 3-12 months for the first five years after a breast cancer diagnosis, then annually thereafter. If a patient has breast-conserving surgery, annual mammography is recommended to assess for local-regional recurrences, although no routine breast imaging is indicated following mastectomy. Given the low risk of distant metastasis and lack of improved outcomes with regular systemic screening, routine laboratory or imaging studies for distant metastases screening are not currently recommended in the absence of clinical signs and/or symptoms of recurrence.1
References
- AJCC Cancer Staging Manual (ed 8th). New York, NY, Springer International Publishing, 2016.
- Plichta JK, Ren Y, Thomas SM, et al. Implications for Breast Cancer Restaging Based on the 8th Edition AJCC Staging Manual. Ann Surg, 2018.
- Weiss A, Chavez-MacGregor M, Lichtensztajn DY, et al. Validation Study of the American Joint Committee on Cancer Eighth Edition Prognostic Stage Compared With the Anatomic Stage in Breast Cancer. JAMA Oncol 4:203-209, 2018.
- Gradishar WJ, Moran MS, Abraham J, et al. Breast Cancer, Version 1.2024, NCCN Clinical Practice Guidelines in Oncology. Online, National Comprehensive Cancer Network, 2024
