What’s Your Stage?-Notes on biologic factors in the 8th Edition Cancer Staging Manual

Breast cancer illus

Read on as our Director of Education, Martha McCormick, explains the 8th Edition Cancer Staging Manual as it pertains to a breast cancer diagnosis.

A breast cancer diagnosis generates complex feelings, fears and questions. It also brings a whole new language and terminology to learn. The vocabulary of Breast Cancer includes words such as Oncotype, Bilateral, Lymphedema, and acronyms like DCIS, LCIS, HER2, and BRCA. Another word that becomes important is “Stage”. You learn that you don’t just have Breast Cancer. You have Stage 0, I, II, or higher Breast Cancer.

Classification by staging of Breast Cancer began in 1959 and is used worldwide. It classifies as TNM based on size of primary tumor (T), lymph node involve­ment (N), and metastasis to other parts of the body (M). The first Staging Manual for Breast Cancer was published in 1977. It’s purpose was to provide a consistent way for descriptions of particular cancers to be communicated, to assist in treatment decisions and prognosis, and to allow for comparisons.

Today, few would describe their Breast Cancer simply as Stage I, Stage II, etc. They would say “Stage II, Triple Negative” or Stage I, HER2 positive, or Stage I, ER positive, etc. These additional characteristics, known as “biologic factors,” are noted because they are significant for determining treatment and prognosis.

Since the first staging manual was issued, it has been reviewed several times to address scientific and medical progress. The last review in 2010 considered the increasingly utilized biologic factors and prognostic indicators but decided that there was not enough evidence to include them in staging. Years later, in preparation for the 8th edition, it was determined that sufficient research-based evidence existed to warrant inclusion.

Reviewers acknowledged that biologic factors such as grade, hormone receptors, HER2 status and genomic panels have become at least as important as tumor size, lymph node involvement and metastasis in predicting survival. Therefore, in the new edition, adopted in 2018, biologic factors are part of the equation.

So what changes in 2018 and what does not?

The main thing that does not change is that anatomic designations of TNM are still the foundation of the staging framework; indicative that not everyone worldwide has the advantage of genomic testing, tests for hormone receptor status, etc. TNM designation remains an important baseline that can apply anywhere, regardless of the availability of advanced testing and treatment.

The 8th edition classification now incorporates biologic factors as predictors of outcome. These include: Tumor grade, hormone receptor status, and HER2 status; indicators which are known to impact prognosis and treatment options.

Tumor Grade describes the extent to which cancer cells resemble or differ from normal cells in appearance and pro­liferation (how fast they are dividing, growing and dying). Lower grade cancer cells are more similar to normal cells so they proliferate more slowly than higher grade cells, which are less similar to normal cells and proliferate more rapidly. Tumor grade can be an indication of how aggres­sive a particular cancer is and influence how it is treated.

Hormone receptor status indicates the extent to which the individual cancer is affected by Estrogen and Progesterone in the body. Breast cancer that is hormone receptor positive can be treated by therapies that remove or block the hormones. There are different treatment options available for Breast Cancer that is hormone receptor negative.

Another important receptor is the Human Epidermal growth factor Receptor 2 (HER2). HER2 is a protein that promotes growth of cancer cells. Patients who are HER2 positive may have the option of targeted treatments that are often effective; whereas HER2 negative status patients are not eligible for these same treatments. When a negative HER2 status is added to a negative estrogen and a negative proges­terone status, that is considered Triple Negative Breast Cancer, for which there are fewer treatments available currently.

Genomic tests such as the Oncotype DX can be incorporated into evaluation and treatment as appropriate. The Oncotype DX tests Breast Cancer tissue from women whose cancer is estrogen receptor positive. For those estrogen receptor positive cancers of TNM stage 1 - IIIa, the Oncotype DX test can help determine whether chemotherapy would be of benefit and the likelihood of the cancer recurring. For estrogen receptor positive DCIS, stage 0, the test can help determine the likelihood of local (same breast) recurrence and determine the appropriate course of treatment.

Utilization of Genomic Tests, particularly the Oncotype DX, has become increasingly common and evidence as to the value of such tests for managing disease has progressed to the point where results are being factored into guidelines.

Will the staging classification change?

Breast Cancer has been identified as TNM Stage 0 – Stage IV for many years and new classifications will continue to stage breast cancer similarly. However, with the in­corporation of biologic factors to TNM staging, some Breast Cancers could be staged higher or lower. Some cancers, where TNM alone indicates a certain stage, may be upstaged or downstaged based on biologic factors that indicate it is more or less aggressive than others.

It is important to note that it is the classification of the staging that is changed - NOT the treatments. If you were previously a stage IIb you would have received a specific course of treatment based on the TNM factors and on the status of other biologic factors - such as grade, hormone receptor and HER2 status. Treatment with the old staging and the new would likely be identical. Accordingly if you are a long-term survivor, diagnosed and treated before the biologic factors were recognized, your treatment would simply have been based on the what was known and the standard of care at that time.

What if I was diagnosed before 2018 but I am still in treatment? Will my cancer be restaged now?

No, your cancer will not be restaged. The 8th edition goes into practice in 2018. It does not look back.

Could my cancer actually be a higher or lower stage with the new criteria? Does that make a difference?

Some breast cancers might be staged higher or lower in some specific instances. Cancers with certain biologic factors that are known to be more aggressive and/or cur­rently have fewer treatment options such as Triple Negative Breast Cancer may now be staged higher to better reflect the impact of the Triple Negative status. Cancers that might be larger but are hormone positive indicating effective treat­ment options, and/or less aggressive, may be staged lower than previously, also to reflect the impact of those biologic factors and as­sociated treatment options.

If you are told that your Breast Cancer is Stage II, for example, that number itself is less important than understanding why it is that stage and the possible treatment options. Your treatment and prognosis are based on anatomic TNM and known (at the time) biologic factors. That has not changed. Only the staging classification is changed to account for mounting evidence of biologic and other factors on the many variations and progression of this disease. Up until now, the biologic factors have not been classified – just added on as descrip­tors. Now that their impact is recognized as significant in measurable and predictable ways, they are part of the classification and add to its usefulness.

Are there other changes in the Eighth Edition?

There are a number of incremental changes in measure­ments and definitions that reflect ongoing knowledge, evidence and specificity in how the staging system is utilized, and how various breast cancers are treated.

Earlier TNM staging reflected characteristics that could be seen and measured at the time. In recent years, additional characteristics have come to light concerning predictable aggressiveness and response to treatment of different types of breast cancer and these are being factored into the clas­sification when evidence warrants.

-Martha M. McCormick, MS, EdS

Director of Education, To Life!

2017 Women’s Health Conference - In case you missed it….

Women's Health Conference

November 14, 2017

Overview of the day's presentations

Genomics today: What the Research Tells Us

Douglas Conklin, PhD

SUNY Cancer Research Center

Our 7th annual Women’s Health Conference began with an engaging lecture by Dr. Douglas Conklin of the SUNY Cancer Research Center. Dr. Conklin explained that there are four molecular subtypes of breast cancer tumors-luminal A, luminal B, Basal-like and HER2ex, all caused by different DNA mutations in breast cells that can happen over time. He then went on to introduce biochemist Dr. Otto Warburg who hypothesized that cancer growth is caused by cells that use glucose for energy through fermentation, instead of using oxygen through respiration, which occurs in normal body cells. In other words, sugar is a major source of nutrients for cancer cells. This hypothesis has led to the creation of new anti-cancer therapies, which revolve around inhibiting cell intake of glucose, thus interrupting and slowing cancer metabolism. This research also supports the idea that standard recommendations such as maintaining a healthy weight, regulating sugar and alcohol intake, exercising and not smoking have an even bigger impact on preventing cancer or recurrence - great news for many of the survivors in the room!

Advances in the Local Treatment of Breast Cancer

Duncan Savage, MD

Radiation Oncologist at St. Peter’s Hospital, SPHP

Our second speaker was board certified radiation oncologist Dr. Duncan Savage, of St. Peter’s Hospital. Dr. Savage spoke to our audience about the many advances that have occurred in the localized treatment of breast cancer, including radiation therapy, lumpectomy, Oncotype Dx testing, and targeted therapy based on the molecular subtype of breast cancer. We have learned that in many cases of breast cancer, a total mastectomy may not be needed. Instead hormonal therapy, a lumpectomy with a course of radiation, or just radiation could be equally effective in eliminating the cancer and preventing recurrence. In addition, advances in radiation have made it easier to administer effective doses without damaging internal organs, such as the heart. All in all it was a fascinating talk that reminds us of the wealth of treatment options available for breast cancer patients AND how important it is to make shared medical decisions with your oncologist regarding treatment.

Breast Surgery: Then and Now & Breast Cancer Staging

B. Marie Ward, M.D., F.A.C.S.

Division of Breast Surgery, Albany Medical Center

Our third talk of the day was given by Dr. B. Marie Ward, Director of Breast Surgery at Albany Medical Center. Dr. Ward began by taking the audience through a brief history of breast surgery and all of the progress we have made towards localized treatment. In the 21st century, surgeons have adopted a breast conservation approach, which has resulted in the near extinction of radical mastectomies and has increased the instances of lumpectomies, followed by a course of radiation. In addition, oncologists have discovered that chemotherapy is not right for everyone. Oncotype DX testing can tell us a patient’s risk for recurrence and overall survival, as well as the magnitude of chemotherapy response. If a tumor is not likely to respond effectively to chemotherapy than an oncologist can easily spare that patient the process of having to go through chemo. Dr. Ward also touched on the new 8th edition AJCC Breast Cancer Staging system which reflects the many advances made in breast cancer research. The new staging system will still include the old TNM staging (tumor size, lymph node involvement, metastasis), but will also incorporate a tumor’s biological markers, such as whether it is hormone positive or negative.

Break Out Sessions

When Legal Problems Become Health Issues

Alexis Kutski, Esq

Legal Aid Society of Northeastern NY

Alexis Kutski is a staff attorney with the Legal Aid Society of Northeastern New York who spoke to the audience about Legal Aid’s Medical Legal Partnership (MLP) program with St. Peter’s Health Partners and Albany Law School. Ms. Kutski explained that a MLP is defined as collaboration between legal and medical services to address health harming legal problems. Through Legal Aid’s MLP, Ms. Kutski provides free legal services to low-income patients concerning legal issues that relate to and affect the patient’s health. Some of the legal areas addressed through an MLP are housing, legal status, health insurance, disability benefits, personal and family stability, estate planning and power of attorney. The talk contained great information for both breast cancer patients, as well as clinical professionals who may be in need of Legal Aid’s services.

Psychological Issues in Breast Cancer

Edward S. Dick, LCSW


Edward S. Dick is a Clinical Social Worker Specialist in Cambridge, NY who has a wealth of experience helping cancer patients work through the psychological impacts of their diagnoses. In an intimate interview with an audience member, Mr. Dick was able to explain how a cancer diagnosis can often make patients feel alienated, due to the fact that patients each have their own, unique cancer journey that family members and friends may not understand. He also provided great insight into breast cancer diagnoses in particular- that many new breast cancer patients feel guilty, as if somehow they made a mistake or were careless in their health. This feeling is caused by a variety of different factors, such as forgetting to go to an annual mammogram, ignoring a lump, or simply “life getting in the way” of making a doctor’s appointment. Nevertheless, Mr. Dick assured audience members that it is never the patient’s fault and that cancer is often a random occurrence over which the patient has very little control. There are also ways in which patients can combat these feelings of alienation and guilt, such as attending support groups, keeping family and friends updated via email or letters, or writing in a gratitude journal.

Trauma Informed Breast Cancer Treatment and Care

Wendy Gapczynski

DVHRT/Communications Coordinator, YWCA Northeastern NY

Wendy Gapczynski is the Advocacy Coordinator at YWCA NENY, as well as a licensed EMT. She works with Domestic Violence programs and counseling with the YWCA. Through her professional experience working with domestic violence survivors, Wendy was able to explain to the group of clinical professionals how to recognize potential domestic violence cases. Often those suffering in a domestic violence situation may not outright tell you what is going on and it is important to listen carefully and if you suspect violence, ask the patient. In providing resources to a patient in a domestic violence situation it is important to allow him or her autonomy in decision making. As a clinical provider, you can never know exactly what is going on in the patient’s home and it is unwise to make decisions for him or her. Often listening, providing contacts to the nearest YWCA or domestic violence association in the area, and practicing confidentiality best practices are the best courses of action.

Research in Lymphedema Diagnosis & Treatment

Geraldine Pfeiffer, PT CLT-LANA

Geraldine Pfeiffer provided an informative and well researched talk on lymphedema. She began by outlining and defining the stages of lymphedema, focusing on the subtle signs that can lead to an early diagnosis and emphasizing the importance of having baseline measurements for later reference. Further into the talk, Geraldine reviewed known risk factors and steps that can be taken by the patient to reduce incidence and severity of the condition.

Understanding Clinical Trials

Amy Zuchelkowski, RN, MS Clinical Research Manager

New York Oncology Hematology

With feedback from previous Conference participants, we have received numerous requests to present on the topic of clinical trials. Amy Zuchelkowski, the Clinical Research Manager for New York Oncology Hematology is an excellent local resource for information related to ongoing clinical trials. Her talk started out by addressing the four phases of clinical trials, offering a detailed overview of the process from the perspective of the research sponsor. Then Amy addressed patient concerns; prior to starting in the trial and during the trial, then a detailed review of patient risks/benefits and protections.

Radical Remission

Debra Nozik

Discussion of the book Radical Remission – The Nine Key Factors That Can Make A Real Difference, by Dr. Kelly Turner

The book is based on Dr. Turner’s 10 years of research analyzing 1,500 cases of radical remission and looking for commonalities. This led to her doctoral dissertation, a peer-reviewed scientific journal article and then the New York Time’s best-selling book, Radical Remission, which is now in 20 languages.

Dr. Kelly uncovered 75 healing factors – 9 of which were common among all her research subjects. These 9 healing factors uncovered in the research are HYPOTHESES only. There is no guarantee that following these 9 factors will heal cancer. However, separate scientific studies have shown these factors significantly strengthen the immune system. The one factor that should be practiced under the guidance of a health care professional to ensure safety is “Taking Herbs and Supplements”.

I’m So Glad You Asked That Question!- Boutique Q & A’s

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In this edition of I'm So Glad You Asked That Question!, we answer questions from the To Life! Mastectomy Boutique Mailbox. If you have had or may have a mastectomy, these answers are very informative and will explain how To Life!'s mastectomy boutique can help you on your cancer journey.

Dear friends at To Life!,
I had my mastectomy ten years ago and I got a prosthesis from your boutique. It doesn’t seem to be fitting well anymore and now I’m old enough to be on Medicare. What should I do?
Not Fitting

Dear Not Fitting,
I’m so glad you asked that question! First of all, most insurances cover replacement prostheses and bras every two years. Also, To Life! is a Medicare Certified provider so we will take that insurance. Second, and another reason to stay in touch is that all of our bodies change as we age (gravity and all that) so a prosthesis that was perfect back then, may not fit as well ten years later. We always encourage women to come in for a fitting and to see what’s new. There’s no obligation to purchase. We have boutiques in Delmar and Saratoga. We can only see one person at a time and we schedule about one and one half hours for a fitting. Please call for an appointment (518) 439-5975. We’ll be glad to hear from you!

Dear To Life!,
I will be having a mastectomy on one side and don’t want any further surgery. I was planning to get a breast prosthesis but my sister in law is saying that they are so heavy and I won’t like it. I just want to look good and be comfortable.
Not Sure What To Do

Dear Not Sure,
You raise some important concerns. It’s true that a breast form may seem heavy. But that’s for a reason. They are designed to match the weight of an actual breast. Having a single mastectomy and not reconstructing or using a breast prosthesis, can actually be bad for your spine because of the imbalance. Many women develop backaches and discomfort that goes away when they are properly fitted with a breast prosthesis that matches their other breast in size and weight.
While many women opt for reconstruction, others do not want the additional surgery and find prostheses to be a good solution. Also, with some kinds of reconstruction, it can be several months before the process is completed. We can help with solutions or suggestions for looking balanced during that period. Women are more than welcome to visit us BEFORE their surgery to see what is available and learn how the process works. Just give us a call!

Free Cancer Screening Series!

Free Cancer Screening Series!

Sponsored by Cancer Services Center and St. Peter's Health Partners.

Call to make your appointment today! (518) 525-8680.

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FAQs on How to Choose and Buy a Breast Prosthesis and Mastectomy Bra

One of the services offered at To Life! is the proper fitting of breast prostheses (also called breast forms).After breast cancer surgery, a woman can take control of her appearance and boost her self-esteem with the proper fit of a breast prosthesis.This can make a big difference in a woman’s self-image. Read more for  some frequently asked questions and answers concerning breast forms:

“Why should I have a ‘proper fit’?”

A properly fitting breast prosthesis will balance your appearance, prevent your bra from moving around, keep your spine in alignment and balance weight on your shoulders. They are designed to mimic the weight and shape of your natural breast.It is our goal at To Life! to find a prosthesis that is the right size and shape for you and your lifestyle.

“When should I have my first fitting?”

After surgery, your surgeon will recommend the appropriate time for you to start wearing a breast prosthesis. This largely depends upon the post-operative healing process and the type of mastectomy that was performed.While we appreciate that many women in the post-mastectomy phase of recovery are quickly ready to get back to normal or at least establish a “new normal”, it is a good idea to wait at least five to six weeks post-surgery to ensure all swelling has gone down.Your measurements will not be accurate if you are swollen.

“What should I wear to a fitting?”

You should wear what you normally wear in your everyday life.Part of the fitting is seeing how your clothes fit and look when you are wearing the prosthesis.A snug-fitting, design-free top will offer you the best idea of how proportional and symmetrical the breast prosthesis is to your body.

“How are prostheses sized?”

Breast prostheses are available in different shapes, sizes and skin tones.You will be fit to a shape that best conforms to your body shape and matches your existing breast (for unilateral patients).The forms are not sized like a bra so you can't count on getting a form that fits by referencing your bra size.Our fitters can help you find a style and size that works best for you.

“What do they look like?”

Some forms are symmetrical, so they can be used on either side, and some forms are designed to be asymmetrical (used only on your right or left side).

“What are they made of?”

Some are made of silicone and some are made of fiberfill. A silicone breast prosthesis is closest to imitating breast tissue in weight and drape.A good prosthesis will also have some movement similar to your real breast.Some silicone breast prostheses are designed to be worn in the pocket of a mastectomy bra and some are designed to adhere directly to the chest wall.

A fiberfill breast form is very light weight, although some do come “weighted.”It is a good idea to ask your fitter about the pros and cons of a fiberfill breast form.These forms may not be the best option for some women because they may be too light.Fiberfill breast forms are designed to be worn in the pocket of a mastectomy bra.

To Life! has a wide variety of breast prostheses and breast forms and our fitters are knowledgeable in what each form has to offer.The fitters will help you find a prosthesis that's the proper shape, size and weight for your lifestyle and your body.

“Is it comfortable to wear a prosthesis?”

Fit and comfort of a prosthesis is very individual.The prosthesis is designed to mimic the weight of the existing breast and the existing breast can be surprisingly heavy.The industry has come a long way in offering silicone prostheses that are lighter weight and cooler.Our fitters can show you the latest in lightweight silicone prostheses.

“How do I take care of my prosthesis?”

Simply washing them with a mild soap, towel drying them and putting them in their box when they are not being worn is all the care and maintenance they need.

“Will my insurance cover the cost of my prosthesis?”

Insurance companies typically provide coverage for one prosthesis every two years for unilateral patients or two prostheses every two years for bilateral patients.Because of that two-year limit, it is very important to be sized correctly.If you are sized incorrectly, you will not be eligible to re-submit for the correctly sized prosthesis for two years.That is why we recommend waiting until all of your swelling has gone down.

“Do I need a prescription?”

Your doctor will need to write a prescription for “mastectomy bras” and a “breast prosthesis” if you plan to submit these products to your insurance company.

“When do I get the mastectomy bra?”

Your fitting for the breast prosthesis will include a mastectomy bra fitting.The fitter will measure you to determine your bra band size and your cup size.If you have had bilateral surgery, you will tell the fitter the cup size you want to be.To Life! offers many options for mastectomy bras including seamed, seamless, molded cup, camisole bras, and sports bras.

Our goal at To Life! is to ensure your breast prosthesis and mastectomy bra needs are met properly and in a stress-free manner.A proper fitting at the right time is the best way to attain that goal.

“How Much Does a Prosthesis Cost?”

Fitting services at To Life! are complimentary, provided by certified mastectomy fitters. There are costs associated with product. We participate with some insurance companies, including Medicare. However, should we not participate with your insurance company, please know that we have options for supporting your needs and will not turn anyone away. Please feel free to contact us for more detailed information on how we may best serve you.

Our goal at To Life! is to ensure your breast prosthesis and mastectomy bra needs are met properly and in a stress-free manner. A proper fitting at the right time is the best way to attain that goal. Please feel free to contact our fitters with any questions you may have.

Please feel free to contact our fitters with any questions you may have.

Delmar Boutique:Ann Rose (518) 439-5975

Saratoga Boutique:Melanie Murphy (518) 587-3820

Quyen Nguyen: Color-Coded Surgery

Surgeons are taught from textbooks which conveniently color-code the types of tissues, but that's not what it looks like in real life -- until now. At TEDMED, Quyen Nguyen demonstrates how a molecular marker can make tumors light up in neon green, showing surgeons exactly where to cut.

Wellness Therapies

To Life! offers Reiki and Healing Touch at no charge to patients, survivors, and caregivers by appointment.
Each of these therapies promotes relaxation and healing, and clients leave our doors with a sense of calm and positivity.

As one client stated,

"I really enjoyed my [Healing Touch] experience with Shirley.  I left in peace and calm.  The feeling continues today. Oddly for me, tears flowed during the session; I wonder where they came from.  Hmmmm. I haven't cried in years, but it sure felt good!! 

I strongly recommend a session with Shirley for everybody.  The healing touch made the rest of my day pleasant and enjoyable; I was able to relax and enjoy the simple wonders of nature that surround me that I don't notice very often, like the smell of  flowers in my garden, the birds chirping, the magnificient sky.  Truly a magical experience.  It dawned on me that I might just be depressed and Shirley's healing hands greatly affected my mind, body and spirit.  Amazing!!"

--Ruth, Breast Cancer Survivor

To learn more about how Reiki can help manage chronic pain, visit this article: How can Reiki help you?