Understanding a Stage II Breast Cancer Diagnosis
If you’ve been diagnosed with stage II breast cancer (also sometimes written out as stage 2), or know someone who has, you likely have a million questions swirling around your head — but the first one may be, “What does stage II mean?” The most important thing you should know is this: “Any diagnosis of cancer is scary, but stage II breast cancer is a very curable disease,” says Anne Larkin, MD, a breast surgeon at UMass Memorial Health in Worcester, MA.
The staging of the cancer is based on several factors, and it helps your medical team advise you about the best course of treatment and provide you with a realistic prognosis, says Dr. Larkin.
Note: Every person and case is different. While this is an overview of stage II breast cancer, it's important to ask your doctor and their team any questions you have about your diagnosis, treatment and aftercare. Your mental health is also especially important during this time. Reach out to your physician for a referral to a licensed mental health professional to help support you if needed.
First, what exactly does stage II mean?
Breast cancer has traditionally been classified in five stages, from 0 to IV, based on how large the tumor is and how far it has spread in the rest of your body. Stage 0 generally means you have noninvasive cancer or pre-cancer that has not moved outside the breast; as you go up the scale, the tumor generally gets larger and the cancer becomes more invasive— all the way to Stage IV, which means the cancer has spread to other parts of the body, such as the liver, bones or brain.
“Breast cancer stages have historically been based on three different factors,” Dr. Larkin. explains. “The first is the size of the tumor, the second is whether or not the tumor has metastasized to any lymph nodes and the third is whether the tumor has spread to any other places in the body, which is known as metastatic breast cancer.” This staging system is known as TNM, for Tumor, Nodes and Metastasis.
Stage II breast cancer is broken down further into stage IIA and IIB, with these criteria:
Stage IIA:
• Either there is no tumor found in the breast, or there is a tumor up to 2 cm (about the size of a grape) AND cancer has spread to 1 to 3 lymph nodes
• There is a tumor of 2 to 5 cm (the size of a lime), but the cancer has NOT spread to the lymph nodes
Stage IIB:
• There is a tumor of 2 to 5 cm, AND cancer has spread to between 1 and 3 lymph nodes
• There is a tumor larger than 5 cm, but cancer has NOT spread to the lymph nodes or reached the chest wall or skin.
What else do I need to know about cancer staging?
The traditional 0-IV staging of breast cancer based on the TNM system, which was developed in the 1940s, gives us lots of helpful information, but it doesn’t tell the entire story. So in 2016, the American Joint Committee on Cancer (AJCC) added new criteria that takes into account the biologic profile of the tumor and considers patterns of recurrence, sensitivities to different treatments and prognoses. Combined with TNM staging, this provides a much more detailed picture of your cancer. “This staging considers all kinds of other things about a tumor,” says Dr. Larkin. “The way I describe it to patients is: Are the cells happy, are they really aggressive-looking or are they somewhere in between? This really helps us look at which therapies the patient may need.”
This more detailed method of staging cancer means there are more nuances to a stage II diagnosis, adds Jessica Maxwell, MD, a surgical oncologist at Nebraska Medicine. “We may now look at something that we would have traditionally called stage II breast cancer, but if it has a favorable biologic profile, it may get downstaged to something that we would have called a stage I breast cancer based on the size. On the other hand, if a cancer that would have been a stage I has a more worrisome biologic profile, it might get upstaged to stage II.”
Biologic factors included in the staging now include:
Hormone receptors: The tumor is tested to see if the cells contain proteins that bind to the hormones' estrogen (estrogen-receptors, or ER) or progesterone (progesterone receptors, or PR). If the tumor is ER- or PR-positive, it means it need those hormones to grow; a treatment to block estrogen or progesterone can be helpful in slowing or stopping the growth.
HER2 (human epidermal growth factor type 2 receptor): The tumor will also be tested for a protein called HER2, which helps breast cancer cells grow quickly, but also makes them more likely to respond to treatments that target that specific protein.
If the tumor does not show signs of ER, PR or HER2, it is called triple negative. If it has all three, it is called triple positive. Those designations will help your team decide on a plan of treatment.
What are the symptoms of stage II breast cancer?
Symptoms of breast cancer can include:
Lump in the breast or under the armpit
Thickening or swelling of the breast
Irritation or dimpling of breast skin
Pain in the nipple area or the breast in general
Discharge from the nipple (other than breast milk)
Any change in shape or size of the breast
But Dr. Larkin points out that in the case of Stage II breast cancer, there may be no symptoms at all — which is why it is so important to get your annual mammogram.
Note: The CDC has a program called the National Breast and Cervical Cancer Early Detection Program, designed to make sure that women who are uninsured, under-insured and low-income get access to screening for breast cancer, as well as diagnostic and treatment help. The program’s interactive map lets you click on your state to get local information.
What are the treatments for stage II breast cancer?
The treatments for stage II cancer depend not only on the tumor size and its biologic markers, but also your age, overall health and personal preferences. “There are usually multiple modalities of treatment — one treatment in and of itself is usually not enough,” says Dr. Maxwell. “The goal of the treatment is to, number one, get rid of the tumor, and number two, prevent it from coming back as much as possible.” The plan will involve some combination of the following:
Surgery: The tumor will be removed be either via a lumpectomy (also known as breast-conserving surgery, or BCS, this means the cancer is removed while keeping as much of the remaining breast intact as possible), or a mastectomy (in which the entire breast is removed). “The type of surgery is dependent on a few different things. Number one is the tumor size, but probably more importantly, we consider the tumor size in relation to the patient's breast size,” Dr. Maxell explains. “If someone has a two-centimeter tumor, which is not very big, but she has very small breasts, then she might need a mastectomy, because just taking out the tumor with a lumpectomy would not her with a breast that really looks like a breast anymore.” Most surgeries will also remove some or all of the lymph nodes under the armpit on the side of the tumor to determine if the cancer has spread, or to clear out disease if it has indeed spread, she adds.
Chemotherapy: This treatment involves a combination of drugs that are administered orally or intravenously to either destroy cancer cells or slow down their growth — you may undergo chemo before surgery to shrink a tumor (known as neoadjuvant chemotherapy) or after surgery. Whereas the type of surgery is generally based on tumor size, medical treatments including chemo are more often based on the biologic profile of the tumor and whether the cancer has spread. “If genomic testing tells us that there's a high likelihood that the tumor is going to come back, then we will recommend chemotherapy for the patient,” Dr. Larkin explains, adding that due to genomic testing, chemotherapies are much more tailored now to the individual tumor.
Radiation: This treatment involves using high energy rays to destroy cancer cells. If you had a lumpectomy, radiation may be recommended to make sure no cancer cells linger in the remaining breast tissue. If you had a mastectomy but there were also cancer cells found in your lymph nodes, radiation may also be recommended.
Hormone therapy: If your cancer is ER- or PR-positive, your oncologist may recommend hormone therapy to keep the cancer from growing or coming back. Tamoxifen keeps estrogen or progesterone from binding to cancer cells, and is usually taken for 5-10 years after surgery; aromatase inhibitors including Arimidex, Aromasin and Femara, decrease the amount of estrogen in the body.
HER2-targeted therapy: Some women with HER2-positive cancer will be treated before and after surgery with drugs that block the signals telling the cancer to grow.
Immunotherapy: In certain cases of triple-negative breast cancer, treatment might include an immunotherapy drug called pembrolizumab, both before and after surgery. “Immunotherapy is being aggressively studied and has just recently been approved for treatment of more advanced breast cancers including stage two breast cancers in the right setting,” says Dr. Larkin.
What is the survival rate for stage II breast cancer?
If you are diagnosed with stage II breast cancer, you have an excellent chance of being cured and living a long and healthy life. According to the Susan G. Komen Foundation, the five-year survival rate for stage II is 90-99%.
“I always tell patients that there are certain things that we have to do to get the cancer treated. but overall, the goal for treatment for stage II breast cancer is to be disease-free and to live a long and healthy life afterwards — and there is a very excellent chance that that can happen,” says Dr. Maxwell.
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