American Cancer Society Types of Breast

cancer.org | 1.800.227.
2345
Understanding a Breast Cancer

Diagnosis
Types of Breast Cancer
There are several types of breast cancer. The type of breast cancer you have depends
on where in the breast it started and other factors.
● Types of Breast Cancer Overview

● Ductal Carcinoma in Situ (DCIS)
● Invasive Breast Cancer (IDC/ILC)
● Triple-negative Breast Cancer
● Angiosarcoma of the Breast
● Inflammatory Breast Cancer
● Paget Disease of the Breast
Breast Cancer Grade and Other Tests
Doctors use information from your breast biopsy to learn a lot of important things about
the exact kind of breast cancer you have.
● Breast Cancer Grades

● Breast Cancer Ploidy and Cell Proliferation
● Breast Cancer Hormone Receptor Status
● Breast Cancer HER2 Status
● Breast Cancer Gene Expression Tests
● Understanding Your Pathology Report
Stages and Outlook (Prognosis)
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If you have been diagnosed with breast cancer, tests will be done to find out the extent
(stage) of the cancer. The stage of a cancer helps determine how serious the cancer is
and how best to treat it.
● Breast Cancer Stages

● Breast Cancer Survival Rates
Questions to Ask About Your Breast Cancer
You can take an active role in your breast cancer care by learning about your cancer
and its treatment and by asking questions. Get a list of key questions here.
● Questions to Ask Your Doctor About Breast Cancer
Connect with a breast cancer survivor
Reach To Recovery
The American Cancer Society Reach To Recovery® program connects people facing
breast cancer – from diagnosis through survivorship – with trained volunteers who are
breast cancer survivors. Our volunteers provide one-on-one support through our
website and mobile app to help those facing breast cancer cope with diagnosis,
treatment, side effects, and more.
Types of Breast Cancer

There are many types of breast cancer, and many different ways to describe them. It’s
easy to get confused over a breast cancer diagnosis.
The type of breast cancer is determined by the specific cells in the breast that are
affected. Most breast cancers are carcinomas, which are tumors that start in the
epithelial cells that line organs and tissues throughout the body. When carcinomas form
in the breast, they are usually a more specific type called adenocarcinoma, which starts
in cells in the ducts (the milk ducts) or the lobules (milk-producing glands).
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In situ vs. invasive breast cancers
The type of breast cancer can also refer to whether the cancer has spread or not. In situ
breast cancer (ductal carcinoma in situ or DCIS) is a cancer that starts in a milk duct
and has not grown into the rest of the breast tissue. The term invasive (or infiltrating)
breast cancer is used to describe any type of breast cancer that has spread (invaded)
into the surrounding breast tissue.
Ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS; also known as intraductal carcinoma) is a non-invasive
or pre-invasive breast cancer.
Invasive breast cancer (ILC or IDC)

Invasive (or infiltrating) breast cancer has spread into surrounding breast tissue. The
most common types are invasive ductal carcinoma and invasive lobular
carcinoma. Invasive ductal carcinoma makes up about 70-80% of all breast cancers.
Special types of invasive breast cancers
Some invasive breast cancers have special features or develop in different ways that
affect their treatment and outlook. These cancers are less common but can be more
serious than other types of breast cancer.
Triple-negative breast cancer

Triple-negative breast cancer is an aggressive type of invasive breast cancer that
accounts for about 15% of all breast cancers. It is a difficult cancer to treat.
Inflammatory breast cancer

Inflammatory breast cancer is an uncommon type of invasive breast cancer. It accounts
for about 1% to 5% of all breast cancers.
Less common types of breast cancer
There are other types of breast cancers that affect other types of cells in the breast.
These cancers are much less common, and sometimes need different types of
treatment.
Paget disease of the breast

Paget disease of the breast starts in the breast ducts and spreads to the skin of the
nipple and then to the areola (the dark circle around the nipple). It is rare, accounting for
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only about 1-3% of all cases of breast cancer.
Phyllodes tumor 1
Phyllodes tumors are rare breast tumors. They develop in the connective tissue
(stroma) of the breast, in contrast to carcinomas, which develop in the ducts or lobules.
Most are benign, but there are others that are malignant (cancer).
Angiosarcoma
Sarcomas of the breast are rare making up less than 1% of all breast
cancers. Angiosarcoma starts in cells that line blood vessels or lymph vessels. It can
involve the breast tissue or the skin of the breast. Some may be related to prior
radiation therapy in that area.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/non-cancerous-breast-conditions/phyllodes-
tumors-of-the-breast.html
References
Anders CK and Carey LA. ER/PR negative, HER2-negative (triple-negative) breast

cancer. UpToDate website. https://www.uptodate.com/contents/er-pr-negative-her2-
negative-triple-negative-breast-cancer. Updated June 06, 2019. Accessed July 23,
2019.
Calhoun KE, Allison KH, Kim JN et al. Chapter 62: Phyllodes Tumors. In: Harris JR,
Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed.
Philadelphia, Pa: Lippincott-Williams & Wilkins; 2014.
Dillon DA, Guidi AJ, Schnitt SJ. Ch. 25: Pathology of invasive breast cancer. In: Harris
JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed.
Esteva FJ and Gutiérrez C. Chapter 64: Nonepithelial Malignancies of the Breast. In:
Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed.
Henry NL, Shah PD, Haider I, Freer PE, Jagsi R, Sabel MS. Chapter 88: Cancer of the
Breast. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds.
Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa: Elsevier; 2020.
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Jagsi R, King TA, Lehman C, Morrow M, Harris JR, Burstein HJ. Chapter 79: Malignant
Tumors of the Breast. In: DeVita VT, Lawrence TS, Lawrence TS, Rosenberg SA, eds.
DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th
ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology:

Breast Cancer. Version 2.2019. Accessed at
https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on July 23, 2019.
Nora M. Hansen. Chapter 63: Paget's Disease. In: Harris JR, Lippman ME, Morrow M,
Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia, Pa: Lippincott-Williams
& Wilkins; 2014.
Overmoyer B and Pierce LJ. Chapter 59: Inflammatory Breast Cancer. In: Harris JR,
Last Revised: September 20, 2019
Ductal Carcinoma In Situ (DCIS)

About 1 in 5 new breast cancers will be ductal carcinoma in situ (DCIS). Nearly all
women with this early stage of breast cancer can be cured.
DCIS is also called intraductal carcinoma or stage 0 breast cancer. DCIS is a non-
invasive or pre-invasive breast cancer. This means the cells that line the ducts have
changed to cancer cells but they have not spread through the walls of the ducts into the
nearby breast tissue.
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Because DCIS hasn’t spread into the breast tissue around it, it can’t spread
(metastasize) beyond the breast to other parts of the body.
However, DCIS can sometimes become an invasive cancer. At that time, the cancer
has spread out of the duct into nearby tissue, and from there, it could metastasize to
other parts of the body.
Right now, there’s no good way to know for sure which will become invasive cancer and
which ones won’t, so almost all women with DCIS will be treated.
Treating DCIS
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In most cases, a woman with DCIS can choose between breast-conserving surgery
(BCS) and simple mastectomy.
See Treatment for Ductal Carcinoma in Situ (DCIS)1 to learn more.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/treatment/treatment-of-breast-cancer-by-
stage/treatment-of-ductal-carcinoma-in-situ-dcis.html
References
Corben AD and Brogi E. Chapter 21: Ductal Carcinoma In Situ and Other Intraductal
Lesions: Pathology, Immunohistochemistry, and Molecular Alterations. In: Harris JR,

Van Zee KJ, White J, Morrow M, and Harris JR. Chapter 23: Ductal Carcinoma In Situ
and Microinvasive Carcinoma. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds.
Diseases of the Breast. 5th ed. Philadelphia, Pa: Lippincott-Williams & Wilkins; 2014.
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Invasive Breast Cancer (IDC/ILC)

Breast cancers that have spread into surrounding breast tissue are known as invasive
breast cancer.
Most breast cancers are invasive, but there are different types of invasive breast
cancer. The two most common are invasive ductal carcinoma and invasive lobular
carcinoma.
Inflammatory breast cancer and triple negative breast cancer are also types of invasive
breast cancer.
Invasive (infiltrating) ductal carcinoma (IDC)
This is the most common type of breast cancer. About 8 in 10 invasive breast cancers
are invasive (or infiltrating) ductal carcinomas (IDC).
IDC starts in the cells that line a milk duct in the breast. From there, the cancer breaks
through the wall of the duct, and grows into the nearby breast tissues. At this point, it
may be able to spread (metastasize) to other parts of the body through the lymph
system and bloodstream.
Invasive lobular carcinoma (ILC)
About 1 in 10 invasive breast cancers is an invasive lobular carcinoma (ILC).
ILC starts in the milk-producing glands (lobules). Like IDC, it can spread (metastasize)
to other parts of the body. Invasive lobular carcinoma may be harder to detect on
physical exam and imaging, like mammograms, than invasive ductal carcinoma. And
compared to other kinds of invasive carcinoma, about 1 in 5 women with ILC might have
cancer in both breasts.
Less common types of invasive breast cancer
There are some special types of breast cancer that are sub-types of invasive
carcinoma. They are less common than the breast cancers named above and each
typically make up fewer than 5% of all breast cancers. These are often named after
features seen when they are viewed under the microscope, like the ways the cells are
arranged.
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Some of these may have a better prognosis than the more common IDC. These include:
● Adenoid cystic (or adenocystic) carcinoma

● Low-grade adenosquamous carcinoma (this is a type of metaplastic carcinoma)
● Medullary carcinoma
● Mucinous (or colloid) carcinoma
● Papillary carcinoma
● Tubular carcinoma
Some sub-types have the same or maybe worse prognoses than IDC. These include:
● Metaplastic carcinoma (most types, including spindle cell and squamous, except
low grade adenosquamous carcinoma)
● Micropapillary carcinoma
● Mixed carcinoma (has features of both invasive ductal and lobular)
In general, all of these sub-types are still treated like IDC.
Treating invasive breast cancer
Treatment of invasive breast cancer depends on how advanced the cancer is (the stage
of the cancer) and other factors. Most women will have some type of surgery to remove
the tumor. Depending on the type of breast cancer and how advanced it is, you might
need other types of treatment as well, either before or after surgery, or sometimes both.
See Treating Breast Cancer1 for details on different types of treatment, as well as
common treatment approaches based on the stage or other factors.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/treatment.html
References
Arpino G, Infiltrating lobular carcinoma of the breast:tumor board characteristics and

clinical outcome. Breast Cancer Research. 2004; 6: 149.
Dillon DA, Guidi AJ, Schnitt SJ. Ch. 25: Pathology of invasive breast cancer. In: Harris
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JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed.
Huober J, Gelber S, Goldhirsch A, et al. Prognosis of medullary breast cancer: analysis

of 13 International Breast Cancer Study Group (IBCSG) trials. Ann Oncol.
2012;23(11):2843–2851.
Nora M. Hansen. Chapter 63: Paget's Disease. In: Harris JR, Lippman ME, Morrow M,
Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia, Pa: Lippincott-Williams
& Wilkins; 2014.
Overmoyer B and Pierce LJ. Chapter 59: Inflammatory Breast Cancer. In: Harris JR,
Triple-negative Breast Cancer

Triple-negative breast cancer (TNBC) accounts for about 10-15% of all breast cancers.
The term triple-negative breast cancer refers to the fact that the cancer cells don’t have
estrogen or progesterone receptors and also don’t make too much of the protein called
HER2. (The cells test "negative" on all 3 tests.) These cancers tend to be more common
in women younger than age 40, who are African-American, or who have a BRCA1
mutation.
Triple-negative breast cancer differs from other types of invasive breast cancer in that
they grow and spread faster, have limited treatment options, and a worse prognosis
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(outcome).
Signs and symptoms of triple-negative breast cancer
Triple-negative breast cancer can have the same signs and symptoms1 as other
common types of breast cancer.
How is triple-negative breast cancer diagnosed?
Once a breast cancer diagnosis has been made using imaging tests and a biopsy2, the
cancer cells will be checked for certain features. If the cells do not have estrogen or
progesterone receptors, and also do not make too much of the HER2 protein, the
cancer is considered to be triple-negative breast cancer.
Survival rates for triple-negative breast cancer
Triple-negative breast cancer (TNBC) is considered an aggressive cancer because it

grows quickly, is more likely to have spread at the time it’s found and is more likely to
come back after treatment than other types of breast cancer. The outlook is generally
not as good as it is for other types of breast cancer.
Survival rates can give you an idea of what percentage of people with the same type
and stage of cancer are still alive a certain amount of time (usually 5 years) after they
were diagnosed. They can’t tell you how long you will live, but they may help give you a
better understanding of how likely it is that your treatment will be successful.
Keep in mind that survival rates are estimates and are often based on previous
outcomes of large numbers of people who had a specific cancer, but they can’t
predict what will happen in any particular person’s case. These statistics can be
confusing and may lead you to have more questions. Talk with your doctor about
how these numbers may apply to you, as he or she is familiar with your situation.
What is a 5-year relative survival rate?
A relative survival rate compares women with the same type and stage of breast
cancer to women in the overall population. For example, if the 5-year relative survival
rate for a specific stage of breast cancer is 90%, it means that women who have that
cancer are, on average, about 90% as likely as women who don’t have that cancer to
live for at least 5 years after being diagnosed.
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Where do these numbers come from?
The American Cancer Society relies on information from the SEER* database,
maintained by the National Cancer Institute (NCI), to provide survival statistics for
different types of cancer.
The SEER database tracks 5-year relative survival rates for breast cancer in the United
States, based on how far the cancer has spread. The SEER database, however, does
not group cancers by AJCC TNM stages (stage 1, stage 2, stage 3, etc.). Instead, it
groups cancers into localized, regional, and distant stages:
● Localized: There is no sign that the cancer has spread outside of the breast.
● Regional: The cancer has spread outside the breast to nearby structures or lymph
nodes.
● Distant: The cancer has spread to distant parts of the body such as the lungs, liver
or bones.
5-year relative survival rates for triple-negative breast cancer
(Based on women diagnosed with triple-negative breast cancer between 2010 and
2015.)
SEER Stage 5-year Relative Survival Rate
Localized 91%
Regional 65%
Distant 11%
Understanding the numbers
● Women now being diagnosed with triple negative breast cancer may have a
better outlook than these numbers show. Treatments improve over time, and
these numbers are based on women who were diagnosed and treated at least four
to five years earlier.
● These numbers apply only to the stage of the cancer when it is first
diagnosed. They do not apply later on if the cancer grows, spreads, or comes back
after treatment.
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● These numbers don’t take everything into account. Survival rates are grouped
based on how far the cancer has spread, but your age, overall health, how well the
cancer responds to treatment, tumor grade, and other factors can also affect your
outlook.
Treating triple-negative breast cancer
Triple-negative breast cancer has fewer treatment options than other types of invasive
breast cancer. This is because the cancer cells do not have the estrogen or
progesterone receptors or enough of the HER2 protein to make hormone therapy or
targeted drugs work.
If the cancer has not spread to distant sites, surgery is an option. Chemotherapy might
be given first to shrink a large tumor followed by surgery. It might also be given after
surgery to reduce the chances of the cancer coming back. Radiation might also be an
option depending on certain features of the tumor.
Because hormone therapy and HER2 drugs are not choices for women with triple
negative breast cancer, chemotherapy is often used. In cases where the cancer has
spread to other parts of the body (stage IV) chemotherapy and other treatments that
can be considered include PARP inhibitors, platinum chemotherapy, or immunotherapy.
For details, see Treatment of Triple-negative Breast Cancer3.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/about/breast-cancer-signs-and-
symptoms.html
2. www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection.html
3. www.cancer.org/cancer/breast-cancer/treatment/treatment-of-triple-negative.html
References
Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z,

Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics
Review, 1975-2016, National Cancer Institute. Bethesda, MD,
https://seer.cancer.gov/csr/1975_2016/, based on November 2018 SEER data
submission, posted to the SEER web site, April 2019.
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Jhan JR, Andrechek ER. Triple-negative breast cancer and the potential for targeted
therapy. Pharmacogenomics. 2017;18(17):1595–1609.

https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on August 5, 2019.
Li X, Yang J, Peng L, Sahin AA, Huo L, Ward KC, O'Regan R, Torres MA, Meisel JL.
Triple-negative breast cancer has worse overall survival and cause-specific survival
than non-triple-negative breast cancer. Breast Cancer Res Treat. 2017 Jan;161(2):279-
287.
Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is rare and accounts for only 1-5% of all breast
cancers. Although it is often a type of invasive ductal carcinoma, it differs from other
types of breast cancer in its symptoms, outlook, and treatment. IBC has symptoms of
inflammation like swelling and redness, but infection or injury do not cause IBC or the
symptoms. IBC symptoms are caused by cancer cells blocking lymph vessels in the
skin causing the breast to look "inflamed."
Symptoms include breast swelling, purple or red color of the skin, and dimpling or
thickening of the skin of the breast so that it may look and feel like an orange peel.
Often, you might not feel a lump, even if it is there. If you have any of these symptoms,
it does not mean that you have IBC, but you should see a doctor right away.
How is inflammatory breast cancer different from other types of

breast cancer?
Inflammatory breast cancer differs (IBC) from other types of breast cancer in several
ways:
● IBC doesn't look like a typical breast cancer. It often does not cause a breast lump,
and it might not show up on a mammogram. This makes it harder to diagnose.
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● IBC tends to occur in younger women (younger than 40 years of age).

● African-American women appear to develop IBC more often than white women.
● IBC is more common among women who are overweight or obese.
● IBC also tends to be more aggressive—it grows and spreads much more
quickly—than more common types of breast cancer.
● IBC is always at a locally advanced stage when it’s first diagnosed because the
breast cancer cells have grown into the skin. (This means it is at least stage III.)
● In about 1 of every 3 cases, IBC has already spread (metastasized) to distant parts
of the body when it is diagnosed. This makes it harder to treat successfully.
● Women with IBC tend to have a worse prognosis (outcome) than women with other
common types of breast cancer.
Signs and symptoms of inflammatory breast cancer
Inflammatory breast cancer (IBC) causes a number of signs and symptoms, most of
which develop quickly (within 3-6 months), including:
● Swelling (edema) of the skin of the breast

● Redness involving more than one-third of the breast
● Pitting or thickening of the skin of the breast so that it may look and feel like an
orange peel
● A retracted or inverted nipple
● One breast looking larger than the other because of swelling
● One breast feeling warmer and heavier than the other
● A breast that may be tender, painful or itchy
● Swelling of the lymph nodes under the arms or near the collarbone
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Tenderness, redness, warmth, and itching are also common symptoms of a breast
infection or inflammation, such as mastitis if you’re pregnant or breastfeeding. Because
these problems are much more common than IBC, your doctor might suspect infection
at first as a cause and treat you with antibiotics.
This may be a good first step, but if your symptoms don’t get better in 7 to 10 days,
more tests need to be done to look for cancer. The possibility of IBC should be
considered more strongly if you have these symptoms and are not pregnant or
breastfeeding, or have been through menopause.
IBC grows and spreads quickly, so the cancer may have already spread to nearby
lymph nodes by the time symptoms are noticed. This spread can cause swollen lymph
nodes under your arm or above your collar bone. If the diagnosis is delayed, the cancer
can spread to distant sites.
If you have any of these symptoms, it does not mean that you have IBC, but you should
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see a doctor right away. If treatment with antibiotics is started, you’ll need to let your
doctor know if it doesn't help, especially if the symptoms get worse or the affected area
gets larger. Ask to see a specialist (like a breast surgeon) or you might want to get a
second opinion if you’re concerned.
How is inflammatory breast cancer diagnosed?
Imaging tests
If inflammatory breast cancer (IBC) is suspected, one or more of the following imaging
tests may be done:
● Mammogram1
● Breast ultrasound2
● Breast MRI (magnetic resonance imaging) scan3
Sometimes a photo of the breast is taken to help record the amount of redness and
swelling before starting treatment.
Biopsy
Breast cancer is diagnosed by a biopsy4, taking out a small piece of the breast tissue
and looking at it in the lab. Your physical exam and other tests may show findings that
are "suspicious for" IBC, but only a biopsy can tell for sure that it is cancer.
Tests on biopsy samples
The cancer cells in the biopsy will be examined in the lab to determine their grade.
They will also be tested for certain proteins that help decide which treatments will be
helpful. Women whose breast cancer cells have hormone receptors are likely to benefit
from treatment with hormone therapy drugs.
Cancer cells that make too much of a protein called HER2 or too many copies of the
gene for that protein may be treated by certain drugs that target HER2.
Stages of inflammatory breast cancer
All inflammatory breast cancers start as Stage III (T4dNXM0) since they involve the
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skin. If the cancer has spread outside the breast to distant areas it is stage IV.
For more information, read about breast cancer staging.
Survival rates for inflammatory breast cancer
Inflammatory breast cancer (IBC) is considered an aggressive cancer because it grows

quickly, is more likely to have spread at the time it’s found, and is more likely to come
back after treatment than other types of breast cancer. The outlook is generally not as
good as it is for other types of breast cancer.
cancer to women in the overall population. For example, if the 5-year relative survival
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nodes.
or bones.
5-year relative survival rates for inflammatory breast cancer
(Based on women diagnosed with inflammatory breast cancer between 2009 and 2015.)

Regional 52%
Distant 18%
All SEER Stages 39%
● Women now being diagnosed with inflammatory breast cancer may have a
better outlook than these numbers show. Treatments improve over time, and
these numbers are based on women who were diagnosed and treated at least four
to five years earlier.
after treatment.
cancer responds to treatment, tumor grade, and other factors can also affect your
outlook.
*SEER = Surveillance, Epidemiology, and End Results
Treating inflammatory breast cancer
Inflammatory breast cancer (IBC) that has not spread outside the breast or nearby
lymph nodes is stage III. In most cases, treatment is chemotherapy first to try to shrink
the tumor, followed by surgery to remove the cancer. Radiation is given after surgery,
and, in some cases, more treatment may be given after radiation. Because IBC is so
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aggressive, breast conserving surgery (lumpectomy) and sentinel lymph node biopsy
are typically not part of the treatment.
IBC that has spread to other parts of the body (stage IV) may be treated with
chemotherapy, hormone therapy, and/or with drugs that targets HER2.
For details, see Treatment of Inflammatory Breast Cancer5.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/screening-tests-and-early-
detection/mammograms.html
2. www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/breast-
ultrasound.html
3. www.cancer.org/treatment/understanding-your-diagnosis/tests/mri-for-cancer.html
biopsy.html
5. www.cancer.org/cancer/breast-cancer/treatment/treatment-of-inflammatory-breast-
cancer.html
References
American Joint Committee on Cancer. Breast. In: AJCC Cancer Staging Manual. 8th ed.
New York, NY: Springer; 2017:589.
Curigliano G. Inflammatory breast cancer and chest wall disease: The oncologist
perspective. Eur J Surg Oncol. 2018 Aug;44(8):1142-1147.
Hance KW, Anderson WF, Devesa SS, Young HA, Levine PH. Trends in inflammatory
breast carcinoma incidence and survival: the Surveillance, Epidemiology, and End
Results program at the National Cancer Institute. J Natl Cancer Inst. 2005;97:966975.
Hennessy BT, Gonzalez-Angulo AM, Hortobagyi GN, et al. Disease-free and overall
survival after pathologic complete disease remission of cytologically proven
inflammatory breast carcinoma axillary lymph node metastases after primary systemic
chemotherapy. Cancer. 2006;106:10001006.
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Menta A, Fouad TM, Lucci A, Le-Petross H, Stauder MC, Woodward WA, Ueno NT, Lim
B. Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast
Cancer. Surg Clin North Am. 2018 Aug;98(4):787-800.
National Cancer Institute. Inflammatory Breast Cancer. 2016. Accessed at

https://www.cancer.gov/types/breast/ibc-fact-sheet on July 23, 2019.

Overmeyer B and Pierce LJ. Chapter 59: Inflammatory Breast Cancer. In: Harris JR,
Schlichting JA, Soliman AS, Schairer C, Schottenfeld D, Merajver SD. Inflammatory and
non-inflammatory breast cancer survival by socioeconomic position in the Surveillance,
Epidemiology, and End Results database, 1990-2008. Breast Cancer Res Treat. 2012
Aug;134(3):1257-68. Epub 2012 Jun 26.
Scott LC, Mobley LR, Kuo TM, Il'yasova D. Update on triple-negative breast cancer
disparities for the United States: A population-based study from the United States
Cancer Statistics database, 2010 through 2014. Cancer. 2019 Jul 8. doi:
10.1002/cncr.32207. [Epub ahead of print].
Taghian A, El-Ghamry MN and Merajver SD. Inflammatory breast cancer: Clinical

features and treatment. UpToDate website.
https://www.uptodate.com/contents/inflammatory-breast-cancer-clinical-features-and-
treatment. Last updated Sept 26, 2018. Accessed Aug 5, 2019.
Yang WT, Le-Petross HT, Macapinlac H, Carkaci S, Gonzalez-Angulo AM, Dawood S,

Resetkova E, Hortobagyi GN, Cristofanilli M: Inflammatory breast cancer: PET/CT, MRI,
mammography and sonography findings. Breast Cancer Res Treat. 2008
Jun;109(3):417-26. Epub 2007 Jul 26. Review.
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Angiosarcoma of the Breast

Angiosarcoma is rare cancer that starts in the cells that line blood vessels or lymph
vessels. Many times it's a complication of previous radiation treatment to the breast. It
can happen 8-10 years after getting radiation treatment to the breast.
Signs and symptoms of angiosarcoma
Angiosarcoma can cause skin changes like purple colored nodules and/or a lump in the
breast. It can also occur in the affected arms of women with lymphedema, but this is not
common. (Lymphedema is swelling that can develop after surgery or radiation therapy
to treat breast cancer.)
How is angiosarcoma of the breast diagnosed?
One or more of the following imaging tests may be done to check for breast changes:
● Diagnostic mammogram1
Angiosarcoma is diagnosed by a biopsy4, removing a small piece of the breast tissue

and looking at it in the lab. Only a biopsy can tell for sure that it is cancer.
Treating angiosarcoma
Angiosarcomas tend to grow and spread quickly. Treatment usually includes surgery5 to
remove the breast (mastectomy). The axillary lymph nodes are typically not
removed. For more information on sarcomas, see Soft Tissue Sarcoma6.
Hyperlinks
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ultrasound.html
mri-scans.html
biopsy.html
5. www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer.html
6. www.cancer.org/cancer/soft-tissue-sarcoma.html
References
Chugh R, Sabel MS, and Feng M. Breast sarcoma: Epidemiology, risk factors, clinical
presentation, diagnosis, and staging. UpToDate website.
https://www.uptodate.com/contents/breast-sarcoma-epidemiology-risk-factors-clinical-
presentation-diagnosis-and-staging. Updated Aug 28, 2017. Accessed July 23, 2019.
Esteva FJ and Gutiérrez C. Chapter 64: Nonepithelial Malignancies of the Breast. In:
Singer S, Tap WD, Kirsch DG, and Crago AM. Chapter 88: Soft Tissue Sarcoma. In:
DeVita VT, Lawrence TS, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and
Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa:
Lippincott Williams & Wilkins; 2019.
Van Tine BA. Chapter 90: Sarcomas of Soft Tissue. In: Niederhuber JE, Armitage JO,
Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed.
Philadelphia, Pa: Elsevier; 2020.
Paget Disease of the Breast
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Paget disease of the breast is a rare type of breast cancer involving the skin of the
nipple and the areola(the dark circle around the nipple). Paget disease usually affects
only one breast. In 80-90% of cases, it’s usually found along with either ductal
carcinoma in situ (DCIS) or infiltrating ductal carcinoma (invasive breast cancer).
Signs and symptoms of Paget disease of the breast
The skin of the nipple and areola often looks crusted, scaly, and red. There may be
blood or yellow fluid coming out of the nipple. Sometimes the nipple looks flat or
inverted. It also might burn or itch. Your doctor might try to treat this as eczema first,
and if it does not improve, recommend a biopsy.
How is Paget disease of the breast diagnosed?
Most people with Paget disease of the breast also have tumors in the same breast. One
or more of the following imaging tests may be done to check for other breast changes:
● Diagnostic mammogram1
Paget disease of the breast is diagnosed by a biopsy4, removing a small piece of the
breast tissue and looking at it in the lab. In some cases, the entire nipple may be
removed. Only a biopsy can tell for sure that it is cancer.
Treating Paget disease of the breast
Paget disease can be treated by removing the entire breast (mastectomy5) or breast-
conserving surgery6(BCS) followed by whole-breast radiation therapy7. If BCS is done,
the entire nipple and areola area also needs to be removed. If invasive cancer is found,
the lymph nodes under the arm will be checked for cancer.
If no lump is felt in the breast tissue, and your biopsy results show the cancer has not
spread, the outlook (prognosis) is excellent.
If the cancer has spread (is invasive), the outlook is not as good, and the cancer will be
staged and treated like any other invasive ductal carcinoma8.
Hyperlinks
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ultrasound.html
3. www.cancer.org/treatment/understanding-your-diagnosis/tests/mri-for-cancer.html
biopsy.html
5. www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-
cancer/mastectomy.html
6. www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer/breast-
conserving-surgery-lumpectomy.html
7. www.cancer.org/cancer/breast-cancer/treatment/radiation-for-breast-cancer.html
8. www.cancer.org/cancer/breast-cancer/treatment/treatment-of-breast-cancer-by-
stage.html
References

Sabel M and Weaver DL. Paget disease of the breast. UpToDate website.
https://www.uptodate.com/contents/paget-disease-of-the-breast. Updated April 3, 2018.
Accessed July 23, 2019.
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Breast Cancer Hormone Receptor

Status
Breast cancer cells taken out during a biopsy1 or surgery2 will be tested to see if they
have certain proteins that are estrogen or progesterone receptors. When the hormones
estrogen and progesterone attach to these receptors, they fuel the cancer growth.
Cancers are called hormone receptor-positive or hormone receptor-negative based on
whether or not they have these receptors (proteins). Knowing the hormone receptor
status is important in deciding treatment options. Ask your doctor about your hormone
receptor status and what it means for you.
What are estrogen and progesterone receptors?
Receptors are proteins in or on cells that can attach to certain substances in the blood.
Normal breast cells and some breast cancer cells have receptors that attach to the
hormones estrogen and progesterone, and depend on these hormones to grow.
Breast cancer cells may have one, both, or none of these receptors.
● ER-positive: Breast cancers that have estrogen receptors are called ER-positive
(or ER+) cancers.
● PR-positive: Breast cancers with progesterone receptors are called PR-positive (or
PR+) cancers.
● Hormone receptor-positive: If the cancer cell has one or both of the receptors
above, the term hormone-receptive positive (also called hormone-positive or HR+)
breast cancer may be used.
● Hormone receptor-negative: If the cancer cell has neither the estrogen nor the
progesterone receptor, it's called hormone-receptor negative (also called hormone-
negative or HR-).
Keeping the hormones estrogen and progesterone from attaching to the receptors can
help keep the cancer from growing and spreading. There are drugs that can be used to
do this3.
Why is knowing hormone receptor status important?
Knowing the hormone receptor status of your cancer helps doctors decide how to treat
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it. If your cancer has one or both of these hormone receptors, hormone therapy drugs
can be used to either lower estrogen levels or stop estrogen from acting on breast
cancer cells. This kind of treatment is helpful for hormone receptor-positive breast
cancers, but it doesn’t work on tumors that are hormone receptor-negative (both ER-
and PR-negative).
All invasive breast cancers should be tested for both of these hormone receptors either
on the biopsy sample or when the tumor is removed with surgery. About 2 of 3 breast
cancers have at least one of these receptors. This percentage is higher in older women
than in younger women. DCIS should be checked for hormone receptors, too.
What do the hormone receptor test results mean?
A test called an immunohistochemistry (IHC) is used most often to find out if cancer
cells have estrogen and progesterone receptors. The test results will help guide you and
your cancer care team in making the best treatment decisions.
Test results will give you your hormone receptor status. It will say a tumor is hormone
receptor-positive if at least 1% of the cells tested have estrogen and/or progesterone
receptors. Otherwise the test will say the tumor is hormone receptor-negative.
Hormone receptor-positive (or hormone-positive) breast cancer cells have either

estrogen (ER) or progesterone (PR) receptors or both. These breast cancers can be
treated with hormone therapy drugs that lower estrogen levels or block estrogen
receptors. Hormone receptor-positive cancers tend to grow more slowly than those that
are hormone receptor-negative. Women with hormone receptor-positive cancers tend to
have a better outlook in the short-term, but these cancers can sometimes come back
many years after treatment.
Hormone receptor-negative (or hormone-negative) breast cancers have neither

estrogen nor progesterone receptors. Treatment with hormone therapy drugs is not
helpful for these cancers. These cancers tend to grow faster than hormone receptor-
positive cancers. If they come back after treatment, it’s often in the first few years.
Hormone receptor-negative cancers are more common in women who have not yet
gone through menopause.
Triple-negative breast cancer cells don’t have estrogen or progesterone receptors and
also don’t make too much of the protein called HER2. These cancers tend to be more
common in women younger than 40 years of age, who are African-American, or who
have a mutation in the BRCA 1 gene. Triple-negative breast cancers grow and spread
faster than most other types of breast cancer. Because the cancer cells don’t have
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hormone receptors, hormone therapy is not helpful in treating these cancers. And
because they don’t have too much HER2, drugs that target HER2 aren’t helpful, either.
Chemotherapy can still be useful. See Triple-negative Breast Cancer to learn more.
Triple-positive cancers are ER-positive, PR-positive, and HER2-positive. These

cancers can be treated with hormone drugs as well as drugs that target HER2.
Hyperlinks
biopsy.html
3. www.cancer.org/cancer/breast-cancer/treatment/hormone-therapy-for-breast-
cancer.html
References

Hammond MEH. Hormone receptors in breast cancer: Clinical utility and guideline
recommendations to improve test accuracy. UpToDate website.
https://www.uptodate.com/contents/hormone-receptors-in-breast-cancer-clinical-utility-
and-guideline-recommendations-to-improve-test-accuracy. Last updated Nov 13, 2018.
Accessed July 31, 2019.
Rimawi MF and Osborne CK. Chapter 43: Adjuvant Systemic Therapy: Endocrine
Therapy. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the
Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.
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Stearns V and Davidson NE. Chapter 45: Adjuvant Chemo Endocrine Therapy. In:
Philadelphia: Wolters Kluwer Health; 2014.
Breast Cancer HER2 Status

Some women have breast tumors with higher levels of a protein known as HER2 –
these are called HER2-positive breast cancers. Ask your doctor about your HER2
status and what it means for you.
What is HER2 and what does it mean?
HER2 is a growth-promoting protein on the outside of all breast cells. Breast

cancer cells with higher than normal levels of HER2 are called HER2-positive. These
cancers tend to grow and spread faster than other breast cancers, but are much more
likely to respond to treatment with drugs that target the HER2 protein1.
How are breast tumors tested for HER2?
Women newly diagnosed with invasive breast cancers should be tested for HER2.
A biopsy2 or surgery sample of the cancer is usually tested with either

immunohistochemical stains (IHC) or Fluorescent in situ hybridization (FISH).
See Testing Biopsy and Cytology Specimens for Cancer3 and Understanding Your
Pathology Report: Breast Cancer4to get more details about these tests.
What do the test results mean?
The results of HER2 testing will guide you and your cancer care team in making the
best treatment decisions.
It is not clear if one test is more accurate than the other, but FISH is more expensive
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and takes longer to get the results. Often the IHC test is done first.
● If the IHC result is 0 or 1+, the cancer is considered HER2-negative. These

cancers do not respond to treatment with drugs that target HER2.
● If the IHC result is 3+, the cancer is HER2-positive. These cancers are usually
treated with drugs that target HER2.
● If the IHC result is 2+, the HER2 status of the tumor is not clear and is called
"equivocal." This means that the HER2 status needs to be tested with FISH to
clarify the result.
Triple-negative breast tumors don’t have too much HER2 and also don’t have estrogen
or progesterone receptors. They are HER2-, ER-, and PR-negative. Hormone therapy
and drugs that target HER2 are not helpful in treating these cancers. See Triple-
negative Breast Cancer to learn more.
Triple-positive breast tumorsare HER2-, ER-, and PR-positive. These cancers are
treated with hormone drugs as well as drugs that target HER2.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/treatment/targeted-therapy-for-breast-
cancer.html
biopsy.html
3. www.cancer.org/treatment/understanding-your-diagnosis/tests/testing-biopsy-and-
cytology-specimens-for-cancer.html
4. www.cancer.org/treatment/understanding-your-diagnosis/tests/understanding-
your-pathology-report/breast-pathology/breast-cancer-pathology.html
References
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Yamauchi H and Hayes DF. HER2 and predicting response to therapy in breast cancer.
UpToDate website. https://www.uptodate.com/contents/her2-and-predicting-response-
to-therapy-in-breast-cancer. Last updated Sept 05, 2018. Accessed July 31, 2019.
Wolff AC, Hammond MEH, Allison KH, Harvey BE, Mangu PB, Bartlett JMS et al.
Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: American
Society of Clinical Oncology/College of American Pathologists Clinical Practice
Guideline Focused Update. J Clin Oncol. 2018;36(20):2105-2122.
Breast Cancer Gene Expression Tests

Gene expression tests are a form of personalized medicine - a way to learn more about
your cancer and tailor your treatment.
These tests are done on breast cancer cells after surgery or biopsy to look at the
patterns of a number of different genes. This process is sometimes called gene
expression profiling.
The patterns found can help predict if certain early stage breast cancers are likely to
come back after initial treatment. Doctors can also use the information from some of
these tests to know which women will most likely benefit from chemotherapy1 after
breast surgery2.
Testing options
The Oncotype DX, MammaPrint, and Prosigna are examples of tests that look at
different sets of breast cancer genes. More tests are in development. The type of test
that's used will depend on your situation. Keep in mind that these tests are usually used
for early stage cancers, and testing isn’t needed in all cases. For example, if breast
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cancer is advanced, it might be clear that chemotherapy is needed, even without gene
expression testing.
Oncotype DX
The Oncotype DX test is used for stage I, II or IIIa hormone receptor-positive tumors
that have not spread to more than 3 lymph nodes and are HER2 negative. It can also be
used for DCIS (ductal carcinoma in situ or stage 0 breast cancer).
This test looks at a set of 21 genes in cancer cells from tumor biopsy or surgery
samples to get a “recurrence score,” which is a number between 0 and 100. The score
reflects the risk of the breast cancer coming back (recurring) in the next 10 years and
how likely you will benefit from getting chemo after surgery.
● A low score (0-25) means a low risk of recurrence. Most women with low-
recurrence scores do not benefit from chemotherapy and have good outcomes
when treated with hormone therapy.
● A high score (26-100) means a higher risk of recurrence. Women with high-
recurrence scores are more likely to benefit from the addition of chemotherapy to
hormone therapy to help lower the chance of the cancer coming back.
For women age 50 or younger who have a low recurrence score of 16-25, there might
be a small to moderate benefit from the addition of chemotherapy. Talk to your doctor
about your options.
MammaPrint
The MammaPrint test can be used to help determine how likely breast cancers are to
recur in a distant part of the body after treatment. It can be used for any type of invasive
breast cancer that’s 5cm (about 2 inches) or smaller and has spread to no more than 3
lymph nodes. This test can be done regardless of the cancer's hormone and HER2
status.
The test looks at 70 different genes to determine if the cancer is at low risk or high risk
of coming back (recurring) in the next 10 years. The test results come back as either
“low risk” or “high risk.” This test is also being studied as a way to determine whether
certain women might benefit from chemotherapy.
Prosigna
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The Prosigna test can be used to predict the risk of recurrence in the next 10 years in
women who have gone through menopause and whose invasive breast cancers are
hormone receptor-positive. It can be used to test stage I or II cancers that have not
spread to the lymph nodes, or stage II cancers with no more than 3 positive lymph
nodes.
The test looks at 50 genes and classifies the results as low, intermediate, or high risk.
What do the test results mean?
Some gene expression testing can help predict which women will most likely benefit
from chemotherapy after breast surgery. (This is called adjuvant chemotherapy.)
Hormone therapy3 is a standard treatment for hormone receptor-positive breast
cancers, but it’s not always clear when to use chemotherapy. These tests can help
guide that decision. Still, these tests cannot tell any one woman for certain if her cancer
will come back with or without chemotherapy.
These tests continue to be studied in large clinical trials4 to better understand how and
when to best use them. In the meantime, ask your doctor if these tests might be useful
for you.
Hyperlinks
1. www.cancer.org/cancer/breast-cancer/treatment/chemotherapy-for-breast-
cancer.html
3. www.cancer.org/cancer/breast-cancer/treatment/hormone-therapy-for-breast-
cancer.html
4. www.cancer.org/treatment/treatments-and-side-effects/clinical-trials.html
References
Cardoso F, van't Veer LJ, Bogaerts J, Slaets L, Viale G, Delaloge S et al. 70-Gene
Signature as an Aid to Treatment Decisions in Early-Stage Breast Cancer. N Engl J
Med. 2016;375(8):717-29.
Gnant M, Filipits M, Dubsky P, et al. Predicting risk for late metastasis: The PAM50 risk
of recurrence (ROR) score after 5 years of endocrine therapy in postmenopausal
women with HR+ early breast cancer: A study on 1,478 patients for the ABCSG-8 trial.
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Ann Oncol. 2013; 24(Suppl 3): iii29-iii37.
Harris LN, Ismaila N, McShane LM, et al. Use of Biomarkers to Guide Decisions on
Adjuvant Systemic Therapy for Women With Early-Stage Invasive Breast Cancer:
American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol.
2016;34(10):1134–1150.
Knauer M, Mook S, Rutgers EJ, Bender RA, Hauptmann M, van de Vijver MJ et al. The
predictive value of the 70-gene signature for adjuvant chemotherapy in early breast
cancer. Breast Cancer Res Treat. 2010 Apr;120(3):655-61.
Krop I, Ismaila N, Andre F, et al. Use of Biomarkers to Guide Decisions on Adjuvant

Systemic Therapy for Women With Early-Stage Invasive Breast Cancer: American
Society of Clinical Oncology Clinical Practice Guideline Focused Update. J Clin Oncol.
2017;35(24):2838–2847.

https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on Aug 5, 2019.
Paik, S. Development and Clinical Utility of a 21-Gene Recurrence Score Prognostic

Assay in Patients with Early Breast Cancer Treated with Tamoxifen. The Oncologist.
2007;12(6): 631-635.
Sparano JA, Gray RJ, Makower KI, Pritchard KS, Albain DF, Hayes CE, et al.
Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl
J Med. 2018;379(2):111-121.
Sparano JA, Gray RJ, Ravdin PM, Makower DF, Pritchard KI, Albain KS et al. Clinical
and Genomic Risk to Guide the Use of Adjuvant Therapy for Breast Cancer. N Engl J
Med. 2019;380(25):2395-2405.
Wallden B, Storhoff J, Nielsen T, et al. Development and verification of the PAM50-

based Prosigna breast cancer gene signature assay. BMC Med Genomics. 2015;8:54.
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Breast Cancer Ploidy and Cell

Proliferation
Finding out more information about the DNA in the breast cancer cells can help predict
how fast the cancer cells are dividing and growing.
What is ploidy and what does it mean?
The ploidy of cancer cells refers to the amount of DNA they contain.
● If there's a normal amount of DNA in the cells, they are said to be diploid. These
cancers tend to grow and spread more slowly.
● If the amount of DNA is abnormal, then the cells are called aneuploid. These
cancers tend to be more aggressive. (They tend to grow and spread faster.)
Tests of ploidy may help figure out long-term outcomes, but they rarely change
treatment and are considered optional. They are not usually recommended as part of a
routine breast cancer work-up.
What is cell proliferation?
Cell proliferation is how quickly a cancer cell copies its DNA and divides into 2 cells. If
the cancer cells are dividing more rapidly, it means the cancer is faster growing or more
aggressive.
The rate of cancer cell proliferation can be estimated by doing a Ki-67 test . In some
cases, Ki-67 testing to measure cell proliferation may be used to help plan treatment or
estimate treatment outcomes. But test results can vary depending on things like the lab
doing the testing, the testing method, and what part of the tumor is tested.
Another way to determine cell division is the S-phase fraction, which is the percentage
of cells in a sample that are copying their DNA as it gets ready to divide into 2 new cells.
If the S-phase fraction or Ki-67 labeling index is high, it means that the cancer cells are
dividing more rapidly.
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References
Duffy MJ, Harbeck N, Nap M, Molina R, Nicolini A, Senkus E, Cardoso F. Clinical use of
biomarkers in breast cancer: Updated guidelines from the European Group on Tumor
Markers (EGTM). Eur J Cancer. 2017;75:284-298.
Breast Cancer Grades

Knowing a breast cancer’s grade is important to understand how fast it’s likely to grow
and spread.
What is a breast cancer’s grade?
Cancer cells are given a grade when they are removed from the breast and checked in
the lab. The grade is based on how much the cancer cells look like normal cells. The
grade is used to help predict your outcome (prognosis) and to help figure out what
treatments might work best.
A lower grade number (1) usually means the cancer is slower-growing and less
likely to spread.
A higher number (3) means a faster-growing cancer that’s more likely to spread.
Grading breast cancer cells
Three cancer cell features are studied and each is assigned a score. The scores are
then added to get a number between 3 and 9 that is used to get a grade of 1, 2, or 3,
which is noted on your pathology report. Sometimes the terms well differentiated,
moderately differentiated, and poorly differentiated are used to describe the grade
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instead of numbers:
● Grade 1 or well differentiated (score 3, 4, or 5). The cells are slower-growing, and
look more like normal breast tissue.
● Grade 2 or moderately differentiated (score 6, 7). The cells are growing at a
speed of and look like cells somewhere between grades 1 and 3.
● Grade 3 or poorly differentiated (score 8, 9). The cancer cells look very different
from normal cells and will probably grow and spread faster.
Our information about pathology reports1 can help you understand details about your
breast cancer.
Grading ductal carcinoma in situ (DCIS)
DCIS is also graded on how abnormal the cancer cells look.
Necrosis (areas of dead or dying cancer cells) is also noted. If there is necrosis, it
means the tumor is growing quickly.
● The term comedocarcinoma is often used to describe DCIS with a lot of necrosis.
● The term comedonecrosis may be used if a breast duct is filled with dead and dying
cells.
Comedocarcinoma and comedonecrosis are linked to a higher grade of DCIS.
See Understanding Your Pathology Report: Ductal Carcinoma In Situ2 for more on how
DCIS is described.
Hyperlinks
your-pathology-report.html
your-pathology-report/breast-pathology/ductal-carcinoma-in-situ.html
References
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Breast Cancer Stages

After someone is diagnosed with breast cancer, doctors will try to figure out if it has
spread, and if so, how far. This process is called staging. The stage of a cancer
describes how much cancer is in the body. It helps determine how serious the cancer is
and how best to treat1 it. Doctors also use a cancer's stage when talking about survival
statistics.
The earliest stage breast cancers are stage 0 (carcinoma in situ). It then ranges from
stage I (1) through IV (4). As a rule, the lower the number, the less the cancer has
spread. A higher number, such as stage IV, means cancer has spread more. And within
a stage, an earlier letter means a lower stage.
How is the stage determined?
The staging system most often used for breast cancer is the American Joint Committee
on Cancer (AJCC) TNM system. The most recent AJCC system, effective January
2018, has both clinical and pathologic staging systems for breast cancer:
● The pathologic stage (also called thesurgical stage) is determined by examining

tissue removed during an operation.
● Sometimes, if surgery is not possible right away or at all, the cancer will be given a
clinical stage instead. This is based on the results of a physical exam, biopsy, and
imaging tests. The clinical stage is used to help plan treatment. Sometimes, though,
the cancer has spread further than the clinical stage estimates, and may not predict
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the patient’s outlook as accurately as a pathologic stage.
In both staging systems, 7 key pieces of information are used:
● The extent (size) of the tumor (T): How large is the cancer? Has it grown into
nearby areas?
● The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph
nodes? If so, how many?
● The spread (metastasis) to distant sites (M): Has the cancer spread to distant
organs such as the lungs or liver?
● Estrogen Receptor (ER) status: Does the cancer have the protein called an
estrogen receptor?
● Progesterone Receptor (PR) status: Does the cancer have the protein called a
progesterone receptor?
● Her2 status: Does the cancer make too much of a protein called Her2?
● Grade of the cancer (G): How much do the cancer cells look like normal cells?
In addition, Oncotype Dx® Recurrence Score results may also be considered in the
stage in certain circumstances.
Once all of these factors have been determined, this information is combined in a
process called stage grouping to assign an overall stage. For more information see
Cancer Staging2.
Details about the first three factors (the TNM categories) are below. However, the
addition of information about ER, PR, and Her2 status along with grade has made
stage grouping for breast cancer more complex than for other cancers. Because
of this, it is best to ask your doctor about your specific stage and what it means.
Details of the TNM staging system
Numbers or letters after T, N, and M provide more details about each of these factors.
Higher numbers mean the cancer is more advanced.
T categories for breast cancer
T followed by a number from 0 to 4 describes the main (primary) tumor's size and if it
has spread to the skin or to the chest wall under the breast. Higher T numbers mean a
larger tumor and/or wider spread to tissues near the breast.
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TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, or Paget disease of the breast with no associated tumor
mass)
T1 (includes T1a, T1b, and T1c): Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
T3: Tumor is more than 5 cm across.
T4 (includes T4a, T4b, T4c, and T4d): Tumor of any size growing into the chest wall or
skin. This includes inflammatory breast cancer.
N categories for breast cancer
N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph
nodes near the breast and, if so, how many lymph nodes are involved.
Lymph node staging for breast cancer is based on how the nodes look under the
microscope, and has changed as technology has improved. Newer methods have made
it possible to find smaller and smaller collections of cancer cells, but experts haven't
been sure how much these tiny deposits of cancer cells affect outlook.
It’s not yet clear how much cancer in the lymph node is needed to see a change in
outlook or treatment. This is still being studied, but for now, a deposit of cancer cells
must contain at least 200 cells or be at least 0.2 mm across (less than 1/100 of an inch)
for it to change the N stage. An area of cancer spread that is smaller than 0.2 mm (or
fewer than 200 cells) doesn't change the stage, but is recorded with abbreviations (i+ or
mol+) that indicate the type of special test used to find the spread.
If the area of cancer spread is at least 0.2 mm (or 200 cells), but still not larger than 2
mm, it is called a micrometastasis (one mm is about the size of the width of a grain of
rice). Micrometastases are counted only if there aren't any larger areas of cancer
spread. Areas of cancer spread larger than 2 mm are known to affect outlook and do
change the N stage. These larger areas are sometimes called macrometastases, but
are more often just called metastases.
NX: Nearby lymph nodes cannot be assessed (for example, if they were removed
previously).
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N0: Cancer has not spread to nearby lymph nodes.
N0(i+): The area of cancer spread contains fewer than 200 cells and is smaller than 0.2
mm. The abbreviation "i+" means that a small number of cancer cells (called isolated
tumor cells) were seen in routine stains or when a special type of staining technique,
called immunohistochemistry, was used.
N0(mol+): Cancer cells cannot be seen in underarm lymph nodes (even using special
stains), but traces of cancer cells were detected using a technique called RT-PCR. RT-
PCR is a molecular test that can find very small numbers of cancer cells. (This test is
not often used to find breast cancer cells in lymph nodes because the results do not
influence treatment decisions.)
N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts
of cancer are found in internal mammary lymph nodes (those near the breast bone) on
sentinel lymph node biopsy.
N1mi: Micrometastases (tiny areas of cancer spread) in the lymph nodes under the
arm. The areas of cancer spread in the lymph nodes are at least 0.2mm across, but not
larger than 2mm.
N1a: Cancer has spread to 1 to 3 lymph nodes under the arm with at least one area of
cancer spread greater than 2 mm across.
N1b: Cancer has spread to internal mammary lymph nodes on the same side as the
cancer, but this spread could only be found on sentinel lymph node biopsy (it did not
cause the lymph nodes to become enlarged).
N1c: Both N1a and N1b apply.
N2: Cancer has spread to 4 to 9 lymph nodes under the arm, or cancer has enlarged
the internal mammary lymph nodes
N2a: Cancer has spread to 4 to 9 lymph nodes under the arm, with at least one area of
cancer spread larger than 2 mm.
N2b: Cancer has spread to one or more internal mammary lymph nodes, causing them
to become enlarged.
N3: Any of the following:
N3a: either:
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Cancer has spread to 10 or more axillary lymph nodes, with at least one area of cancer
spread greater than 2 mm,
OR
Cancer has spread to the lymph nodes under the collarbone (infraclavicular nodes), with
at least one area of cancer spread greater than 2 mm.
N3b: either:
Cancer is found in at least one axillary lymph node (with at least one area of cancer
spread greater than 2 mm) and has enlarged the internal mammary lymph nodes,
OR
Cancer has spread to 4 or more axillary lymph nodes (with at least one area of cancer
spread greater than 2 mm), and tiny amounts of cancer are found in internal mammary
lymph nodes on sentinel lymph node biopsy.
N3c: Cancer has spread to the lymph nodes above the collarbone (supraclavicular
nodes) with at least one area of cancer spread greater than 2 mm.
M categories for breast cancer
M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for
example, the lungs, liver, or bones.
MX: Distant spread (metastasis) cannot be assessed.
M0: No distant spread is found on x-rays (or other imaging tests) or by physical exam.
cM0(i+): Small numbers of cancer cells are found in blood or bone marrow (found only
by special tests), or tiny areas of cancer spread (no larger than 0.2 mm) are found in
lymph nodes away from the underarm, collarbone, or internal mammary areas.
M1: Cancer has spread to distant organs (most often to the bones, lungs, brain, or
liver).
Examples using the full staging system
Because there are so many factors that go into stage grouping for breast cancer, it's not
42
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possible to describe here every combination that might be included in each stage. The
many different possible combinations mean that two women who have the same stage
of breast cancer might have different factors that make up their stage.
Here are 3 examples of how all of the factors listed above are used to determine the
breast cancer stage:
Example #1
If the cancer size is between 2 and 5 cm (T2) but it has not spread to the nearby lymph
nodes (N0) or to distant organs (M0) AND is:
● Grade 3
● Her2 negative
● ER positive
● PR positive
The cancer stage is IB.
Example #2
If the cancer is larger than 5 cm (T3) and has spread to 4 to 9 lymph nodes under the
arm or to any internal mammary lymph nodes (N2) but not to distant organs (M0) AND
is:
● Grade 2
● Her2 positive
● ER positive
● PR positive
The cancer stage is IB.
Example #3
If the cancer is larger than 5 cm (T3) and has spread to 4 to 9 lymph nodes under the
arm or to any internal mammary lymph nodes (N2) but not to distant organs (M0) AND
is:
● Grade 2
● Her2 negative
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● ER negative
● PR negative
The cancer stage is IIIB.
These are only 3 examples out of many possible combinations of factors. To

understand what your breast cancer stage is, and what it means, talk to your doctor.
Hyperlinks
2. www.cancer.org/treatment/understanding-your-diagnosis/staging.html
References
American Joint Committee on Cancer. Breast. In: AJCC Cancer Staging Manual. 8th ed.
New York, NY: Springer; 2017:589.

https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on August 2, 2019.
Paik, S. Development and Clinical Utility of a 21-Gene Recurrence Score Prognostic

Assay in Patients with Early Breast Cancer Treated with Tamoxifen. The Oncologist.
2007;12(6): 631-635.
Survival Rates for Breast Cancer

44
____________________________________________________________________________________
cancer to women in the overall population.For example, if the 5-year relative survival
nodes.
or bones.
5-year relative survival rates for breast cancer
(Based on women diagnosed with breast cancer between 2009 and 2015.)
Localized 99%
Regional 86%
45
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Distant 27%
All SEER stages combined 90%
● Women now being diagnosed with breast cancer may have a better outlook
than these numbers show. Treatments improve over time, and these numbers are
based on women who were diagnosed and treated at least five years earlier.
after treatment.
cancer responds to treatment, tumor grade, the presence of hormone receptors on
the cancer cells, Her2 status, and other factors can also affect your outlook.
● Survival rates for women with triple-negative breast cancer are different than
those above. See Triple-negative Breast Cancer.
● Survival rates for women with inflammatory breast cancer are different than
those above. SeeInflammatory Breast Cancer.
*SEER= Surveillance, Epidemiology, and End Results
References
American Cancer Society. Cancer Facts & Figures 2020. Atlanta, Ga: American Cancer
Society; 2020.
Ruhl JL, Callaghan C, Hurlbut, A, Ries LAG, Adamo P, Dickie L, Schussler N (eds.)
Summary Stage 2018: Codes and Coding Instructions, National Cancer Institute,
Bethesda, MD, 2018.
Last Revised: January 8, 2020
46
____________________________________________________________________________________
Questions to Ask Your Doctor About

Breast Cancer
It’s important to be able to have frank, open discussions with your cancer care team.
They want to answer all of your questions, so that you can make informed treatment
and life decisions.
Here are some questions that you can use to help better understand your cancer and
your treatment options. Don’t be afraid to take notes and tell the doctors or nurses when
you don’t understand what they’re saying. You might want to bring another person with
you when you see your doctor and have them take notes to help you remember what
was said.
Not all of these questions will apply to you, but they should help get you started. Be sure
to write down some questions of your own. For instance, you might want more
information about recovery times or you may want to ask about nearby or online support
groups where you can talk with other women going through similar situations. You may
also want to ask if you qualify for any clinical trials1.
Keep in mind that doctors aren’t the only ones who can give you information. Other
health care professionals, such as nurses and social workers, can answer some of your
questions. To find out more about speaking with your health care team, see The Doctor-
Patient Relationship2.
When you’re told you have breast cancer
● Exactly what type of breast cancer do I have?

● How big is the cancer? Where exactly is it?
● Has the cancer spread to my lymph nodes or other organs?
● What’s the stage of the cancer? What does that mean?
● Will I need any other tests before we can decide on treatment?
● Do I need to see any other doctors or health professionals?
● What is the hormone receptor status of my cancer? What does this mean?
● What is the HER2 status of my cancer? What does this mean?
● How do these factors affect my treatment options and long-term outlook
(prognosis)?
● What are my chances of survival, based on my cancer as you see it?
● Should I think about genetic testing3? What are my testing options? Should I take a
47
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home-based genetic test? What would be the reasons for and against testing?
● How do I get a copy of my pathology report?
● If I’m concerned about the costs and insurance coverage4 for my diagnosis and
treatment, who can help me?
When deciding on a treatment plan
● How much experience do you have treating this type of cancer?

● Should I get a second opinion5? How do I do that?
● What are my treatment6 choices?
● What treatment do you recommend and why?
● Should I think about taking part in a clinical trial7?
● What would the goal of the treatment be?
● How soon do I need to start treatment?
● How long will treatment last? What will it be like? Where will it be done?
● Should my biopsy tissue be sent for a gene expression test to help decide if
chemotherapy might be helpful for me?
● What should I do to get ready for treatment?
● What risks or side effects are there to the treatments you suggest? Are there things
I can do to reduce these side effects?
● How will treatment affect my daily activities? Can I still work fulltime?
● Will I lose my hair? If so, what can I do about it?
● Will I go through menopause as a result of the treatment? Will I be able to have
children after treatment? Would I be able to breastfeed?
● What are the chances the cancer will come back (recur) after this treatment?
● What would we do if the treatment doesn’t work or if the cancer comes back?
● What if I have transportation problems getting to and from treatment?
If you need surgery
● Is breast-conserving surgery8 (lumpectomy) an option for me? Why or why not?

● What are the positive and negative sides of breast-conserving surgery versus
mastectomy?
● How many surgeries like mine have you done?
● Will you have to take out lymph nodes? If so, would you advise a sentinel lymph
48
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node biopsy? Why or why not?

● What side effects might lymph node removal cause?
● How long will I be in the hospital?
● Will I have stitches or staples at the surgery site? Will there be a drain (tube)
coming out of the site?
● How do I care for the surgery site? Will I need someone to help me?
● What will my breasts look and feel like after my treatment? Will I have normal
feeling in them?
● What will the scar look like?
● Is breast reconstruction surgery9 an option if I want it? What would it mean in my
case?
● Can I have reconstruction at the same time as the surgery to remove the cancer?
What are the reasons for and against having it done right away or waiting until
later?
● What types of reconstruction might be options for me?
● Should I speak with a plastic surgeon about reconstruction options?
● Will I need a breast form (prosthesis), and if so, where can I get one?
● Do I need to stop taking any medications or supplements before surgery?
● When should I call your office if I’m having side effects?
During treatment
Once treatment begins, you’ll need to know what to expect and what to look for. Not all
of these questions may apply to you, but asking the ones that do may be helpful.
● How will we know if the treatment is working?

● Is there anything I can do to help manage side effects?
● What symptoms or side effects should I tell you about right away?
● How can I reach you on nights, holidays, or weekends?
● Will I need to change what I eat during treatment?
● Are there any limits on what I can do?
● Can I exercise during treatment? If so, what kind of exercise should I do, and how
often?
● Can you suggest a mental health professional I can see if I start to feel
overwhelmed, depressed, or distressed?
● Will I need special tests, such as imaging scans or blood tests? How often?
49
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After treatment
● Will I need a special diet after treatment?

● Are there any limits on what I can do?
● Am I at risk for lymphedema?
● What can I do to reduce my risk for lymphedema?
● What should I do if I notice swelling in my arm?
● What other symptoms should I watch for?What kind of exercise should I do now?
● What type of follow-up will I need after treatment?
● How often will I need to have follow-up exams, blood tests, or imaging tests?
● How will we know if the cancer has come back? What should I watch for?
● What will my options be if the cancer comes back?
Hyperlinks
2. www.cancer.org/treatment/finding-and-paying-for-treatment/choosing-your-
treatment-team/the-doctor-patient-relationship.html
3. www.cancer.org/cancer/cancer-causes/genetics.html
4. www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-
insurance.html
5. www.cancer.org/treatment/finding-and-paying-for-treatment/choosing-your-
treatment-team/seeking-a-second-opinion.html
8. www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer/breast-
conserving-surgery-lumpectomy.html
9. www.cancer.org/cancer/breast-cancer/reconstruction-surgery.html
Written by
The American Cancer Society medical and editorial content team

(www.cancer.org/cancer/acs-medical-content-and-news-staff.html)
Our team is made up of doctors and oncology certified nurses with deep knowledge of
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____________________________________________________________________________________
cancer care as well as journalists, editors, and translators with extensive experience in
medical writing.
American Cancer Society medical information is copyrighted material. For reprint

requests, please see our Content Usage Policy (www.cancer.org/about-
us/policies/content-usage.html).
cancer.org | 1.800.227.2345
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cancer.org | 1.800.227.

Understanding a Breast Cancer

● Types of Breast Cancer Overview

Breast Cancer Grade and Other Tests

● Breast Cancer Grades

Stages and Outlook (Prognosis)

● Breast Cancer Stages

Questions to Ask About Your Breast Cancer

● Questions to Ask Your Doctor About Breast Cancer

Connect with a breast cancer survivor

Types of Breast Cancer

In situ vs. invasive breast cancers

Ductal carcinoma in situ (DCIS)

Invasive breast cancer (ILC or IDC)

Special types of invasive breast cancers

Triple-negative breast cancer

Inflammatory breast cancer

Less common types of breast cancer

Paget disease of the breast

only about 1-3% of all cases of breast cancer.

Anders CK and Carey LA. ER/PR negative, HER2-negative (triple-negative) breast

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology:

Last Revised: September 20, 2019

Ductal Carcinoma In Situ (DCIS)

See Treatment for Ductal Carcinoma in Situ (DCIS)1 to learn more.

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology:

Last Revised: September 20, 2019

Invasive Breast Cancer (IDC/ILC)

Invasive (infiltrating) ductal carcinoma (IDC)

Invasive lobular carcinoma (ILC)

About 1 in 10 invasive breast cancers is an invasive lobular carcinoma (ILC).

Less common types of invasive breast cancer

● Adenoid cystic (or adenocystic) carcinoma

In general, all of these sub-types are still treated like IDC.

Treating invasive breast cancer

Arpino G, Infiltrating lobular carcinoma of the breast:tumor board characteristics and

Huober J, Gelber S, Goldhirsch A, et al. Prognosis of medullary breast cancer: analysis

Last Revised: September 20, 2019

Triple-negative Breast Cancer

Signs and symptoms of triple-negative breast cancer

How is triple-negative breast cancer diagnosed?

Survival rates for triple-negative breast cancer

Triple-negative breast cancer (TNBC) is considered an aggressive cancer because it

What is a 5-year relative survival rate?

Where do these numbers come from?

5-year relative survival rates for triple-negative breast cancer

SEER Stage 5-year Relative Survival Rate

Understanding the numbers

Treating triple-negative breast cancer

For details, see Treatment of Triple-negative Breast Cancer3.

Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z,

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology:

Last Revised: September 20, 2019

Inflammatory Breast Cancer

How is inflammatory breast cancer different from other types of

● IBC tends to occur in younger women (younger than 40 years of age).

Signs and symptoms of inflammatory breast cancer

● Swelling (edema) of the skin of the breast

How is inflammatory breast cancer diagnosed?