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Breast Cancer
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Your Guide
to the
Breast Cancer
Pathology Report
Waiting for test results Get all the information you need
When you have all of the test results, When you have all the test information
you and your doctor can make the you need, you and your doctor can
right decisions for you. The analysis of make a final decision about your
the removed tissue can lead to several treatment. Don’t focus too much on any
different reports. Some tests take longer one piece of information by itself. Try to
than others. Not all tests are done by look at the whole picture as you think
the same lab. Most information comes about your options.
within 1 to 2 weeks after surgery, and
Different labs and hospitals may
you will usually have all the results
use different words to describe the
within a few weeks. Your doctor can let
same thing. If there are words in your
you know when the results come in. If
pathology report that are not explained
you don’t hear from your doctor, call
in this booklet, don’t be afraid to ask
the office.
your doctor what they mean.
“The information in your pathology report three lab reports from one surgery. Together,
often comes in bits and pieces. Just after the lab reports make up your pathology
surgery, the cancer cells are first looked at report. Try to keep all your reports in one
under the microscope. Results from additional place, so that when you go for your treatment
studies that require special techniques may evaluations, the doctors will have all the
take longer. So you may have one, two, or information they need.”
2 3
WAIT FOR THE
WHOLE PICTURE (continued)
4 5
READING YOUR
PATHOLOGY REPORT
The pathology report answers questions into the normal tissue around them. Cancer
about a breast abnormality cells may also spread beyond the breast.
Breast tissue can develop abnormalities that The abnormal lump or spot may be found
are sometimes cancerous. Usually breast using mammography or other testing
cancer begins either in the cells of the lobules, methods. A procedure called a biopsy removes
which are milk-producing glands, or the a piece of tissue from the lump or spot to find
ducts, the passages that drain milk from the out if cancer cells are present.
lobules to the nipple.Breast cancers have many
The pathology report will tell you what kinds of
characteristics that help determine the best
cells are present.
treatment.
lobule
In some cases, invasive and non-invasive
muscle
duct breast cancer can both be seen in the
same specimen. It’s important to know that
treatment will be based on the characteristics
of the invasive cancer.
nipple
non-
This is what normal cells invasive invasive
inside a milk duct look cells cells
like under a microscope.
6 7
READING YOUR
PATHOLOGY REPORT (continued)
You may see these descriptions of the How different are the cancer cells
type of cancer cells in your report:
from normal cells?
DCIS (Ductal Carcinoma In Situ). This
is a cancer that is non-invasive. It stays Grade is how different the cancer cells
inside the milk ducts. are from normal cells. Experts compare
the appearance of the cancer cells to
NOTE: There are subtypes of DCIS. You’ll normal breast cells. Based on these
find their names in the word list that begins comparisons, they give a grade to the
on page 34 of this booklet. cancer. Grade is different from stage
LCIS (Lobular Carcinoma In Situ). This (see page 28 for information about
is a tumor that is an overgrowth of cells stage).
that stay inside the milk-making part
There are three cancer grades:
of the breast (called lobules). LCIS is
not a true cancer. It’s a warning sign Grade 1 (low grade or well
of an increased risk for developing an differentiated). Grade 1 cancer cells look
invasive cancer in the future in either a little bit different from normal cells.
breast. They are usually slow-growing.
IDC (Invasive Ductal Carcinoma). This is Grade 2 (intermediate/moderate grade
a cancer that begins in the milk duct but or moderately differentiated). Grade 2
has grown into the surrounding normal cancer cells do not look like normal cells.
tissue inside the breast. This is the most They are growing a little faster than
common kind of breast cancer. normal.
ILC (Invasive Lobular Carcinoma). This Grade 3 (high grade or poorly
is a cancer that starts inside the milk- differentiated). Grade 3 cancer cells look
making glands (called lobules), but very different from normal cells. They are
grows into the surrounding normal fast-growing.
tissue inside the breast.
NOTE: There are other, less common types
of invasive breast cancer. You’ll find their
names in the word list beginning on page
34 of this booklet. For more information, go to:
www.breastcancer.org
MY REPORT SAYS:
The type of cancer I have is_______________ The cancer is: (check one)
________________________________________ . j Grade 1 j Grade 2 j Grade 3
8 9
READING YOUR
PATHOLOGY REPORT (continued)
How fast are the cancer cells In breast cancer, a result of less than
growing? 10% is considered low, 10-20% is
intermediate/borderline, and more
Your pathology report may include than 20% is considered high.
information about the rate of cell
If you have an Oncotype DX test
growth—the proportion of cancer cells
done on the cancer to estimate your
within the tumor that are growing and
recurrence risk, checking Ki-67 levels is
dividing to form new cancer cells. A
included as part of the testing.
higher percentage suggests a faster-
growing, more aggressive cancer, rather •S
-phase fraction. The S-phase fraction
than a slower, less aggressive cancer. number tells you what percentage
of cells in the tissue sample are in
Tests that can measure the rate of cell
the process of copying their genetic
growth include:
information (DNA). This S-phase, short
•K
i-67. Ki-67 is a protein in cells that for “synthesis phase,” happens just
increases as they prepare to divide before a cell divides into two new cells.
into new cells. A staining process can
measure the percentage of tumor In breast cancer, a result of less than
cells that are positive for Ki-67. The 6% is considered low, 6-10% is
more positive cells there are, the more intermediate/borderline, and more
quickly they are dividing and forming than 10% is considered high.
new cells.
MY REPORT SAYS:
The rate of cancer growth is: (check one) Test used: (check one)
j Low j Intermediate/borderline j High j Ki-67 test j S-phase fraction test
10 11
READING YOUR
PATHOLOGY REPORT (continued)
How big is the cancer? Has the whole cancer been removed?
Doctors measure cancers in centimeters When surgery is done to remove the
(cm). The size of the cancer is one of the whole cancer, the surgeon tries to take
factors that determines the stage and out all of the cancer with an extra area,
treatment of the breast cancer. or margin, of normal tissue around it.
This is to be sure that all of the cancer
Size doesn’t tell the whole story. All of
is removed.
the cancer’s characteristics are important.
A small cancer can be very fast-growing The outer edge of the tissue removed
while a larger cancer may be slow-growing, is called the margin of resection. It is
or it could be the other way around. looked at very carefully to see if it is
clear of cancer cells.
Tumor size: 1 cm The pathologist also measures the
distance between the cancer cells and
the margin.
3 cm
5 cm
= 2 inches
MY REPORT SAYS:
The size of the cancer is _______ centimeters.
12 13
READING YOUR
PATHOLOGY REPORT (continued)
Margins around a cancer are described Are there cancer cells in your lymph
in three ways: channels or blood vessels?
Negative. No cancer cells can be seen
The breast has a network of lymph
at the outer edge. Usually, no more
channels and blood vessels that drain
surgery is needed.
fluid and blood from your breast tissue
Positive. Cancer cells come right out back into your body’s circulation. These
to the edge of the tissue. More surgery pathways remove used blood and waste
is usually needed to remove any products.
remaining cancer cells.
There is an increased risk of cancer
Close. Cancer cells are close to the edge coming back when cancer cells are found
of the tissue, but not right at the edge. in the fluid channels of the breast. In
More surgery may be needed. these cases, your doctor may customize
Negative Positive your treatment to reduce this risk.
If lymphatic or blood vessel (vascular)
invasion is found, your pathology report
will say present. If there is no invasion,
the report will say absent.
normal normal NOTE: Lymphatic or vascular invasion is
the edge tissue the edge tissue different from lymph node involvement.
cancer cancer
cells cells
This is a picture of cancer cells that have
NOTE: What is called negative (or clean or spread through the wall of the milk duct
clear) margins can be different from hospital and into the nearby lymph channels.
to hospital. In some hospitals, doctors want
at least 2 millimeters (mm) of normal tissue lymphatic channel
between the edge of the cancer and the
outer edge of the tissue. In other places, breast tissue cancer cells
just one healthy cell is called a negative
margin. 1 cm normal duct cells
blood vessel
wall of milk duct
2 mm
1 inch
MY REPORT SAYS:
The margins are: (check one) Lymphatic or vascular invasion is: (check one)
j Negative j Positive j Close j Present j Absent
14 15
READING YOUR
PATHOLOGY REPORT (continued)
Does the cancer have genes that HER2 status. Your pathology report
affect how the cancer might be usually includes the cancer’s HER2
status. The HER2 gene is responsible for
treated?
making HER2 proteins. These proteins
Genes contain the recipes for the are receptors on breast cells. Under
various proteins a cell needs to stay normal circumstances, HER2 receptors
healthy and function normally. Some help control how a breast cell grows,
genes and the proteins they make divides, and repairs itself. But in about
can influence how a breast cancer 25% of breast cancers, the HER2 gene
behaves and how it might respond to can become abnormal and make too
a specific treatment. Cancer cells from many copies of itself (amplification of
a tissue sample can be tested to see the HER2 gene). Amplified HER2 genes
which genes are normal and which are command breast cells to make too
abnormal. The proteins they make can many receptors (overexpression of the
also be tested. HER2 protein). When this happens, the
If the genetic recipe contains a mistake, overexpressed HER2 receptors shout at
the report will say “genetic mutation” (rather than talk to) the breast cells to
or “genetic abnormality.” An example grow and divide in an uncontrolled way.
is one of the inherited breast cancer This can lead to the development of
gene abnormalities, called BRCA1 or breast cancer.
BRCA2. Testing for BRCA1 and BRCA2 Breast cancers that have amplified HER2
is not part of the standard pathology genes or that overexpress the HER2
workup. (Please see page 25 for more protein are described in the pathology
information on these abnormalities.) report as being HER2-positive. HER2-
If the genetic recipe repeats the same positive breast cancers tend to grow
instruction over and over again, the faster and are more likely to spread and
report will say “gene amplification.” come back when compared with HER2-
Genetic amplification happens when negative breast cancers. But HER2-
a genetic recipe’s repeated instruction positive breast cancers can respond to
causes the gene to make too many targeted treatments that are designed to
copies of itself. work against HER2-positive cancer cells.
20 21
READING YOUR
PATHOLOGY REPORT (continued)
There are four tests for HER2: 4. Inform HER2 Dual ISH test (In Situ
1. IHC test (ImmunoHistoChemistry): Hybridization):
• The IHC test shows whether there is • T he Inform HER2 Dual ISH test
too much HER2-receptor protein in shows whether there are too many
the cancer cells. copies of the HER2 gene in the
• The results of the IHC test can be cancer cells.
0 (negative), 1+ (also negative), 2+ • T he results of the Inform HER2
(borderline), or 3+ (positive; the Dual ISH test can be positive (extra
HER2 protein is overexpressed). copies—amplified) or negative
(normal number of copies—not
2. FISH test (Fluorescence In Situ amplified).
Hybridization):
Find out which test for HER2 you had.
• The FISH test shows whether there This is important. Only cancers that test
are too many copies of the HER2 IHC 3+, FISH positive, SPoT-Light HER2
gene in the cancer cells. CISH positive, or Inform HER2 Dual ISH
• The results of the FISH test can be positive respond to therapy that works
positive (extra HER2 gene copies— against HER2-positive breast cancers.
amplified) or negative (normal An IHC 2+ test result is called borderline.
number of HER2 gene copies—not Research has shown that some HER2
amplified). status test results may be wrong. This
3. SPoT-Light HER2 CISH test is probably because different labs
(Subtraction Probe Technology have different classification rules.
Chromogenic In Situ Hybridization): Each pathologist also may use slightly
different criteria. This usually happens
• The SPoT- Light test shows whether
when test results are borderline (IHC
there are too many copies of the
2+). If you have a 2+ result, you can
HER2 gene in the cancer cells. and should ask to also have the tissue
• The results of the SPoT-Light test tested with the FISH test. If your results
can be positive (extra copies— are negative, you may want to ask your
amplified) or negative (normal doctor if another HER2 test makes sense
number of copies—not amplified). for you.
If the cancer is a recurrence, it’s a good
idea to have it retested, because HER2
MY REPORT SAYS: status can change.
HER2 status is: (check one) Test used: (check one) j IHC j FISH
j Positive j Negative j Borderline j SPoT-Light HER2 CISH j Inform HER2 Dual ISH
22 23
READING YOUR
PATHOLOGY REPORT (continued)
EGFR status. The EGFR gene, much like The Oncotype DX test also is used to
the HER2 gene, can be overexpressed in estimate recurrence risk of DCIS and/
some breast cancer cells and influence or the risk of a new invasive cancer
how the cancer cells behave. Your developing in the same breast, and
pathology report may also contain how likely a person is to benefit from
information about EGFR overexpression. radiation therapy after DCIS surgery.
Genomic assays. Unlike individual
gene testing, such as testing for HER2, Genetic testing that is not a part of
genomic assays analyze the activity of your pathology report
a group of normal and abnormal genes
that can increase the risk of breast Inherited cases of breast cancer are likely
cancer coming back after treatment. associated with abnormal genes. Two of
This analysis can help decide if a person the most common are abnormal versions
is likely to benefit from chemotherapy of BRCA1 (BReast CAncer gene 1) and
to reduce the risk of the cancer coming BRCA2 (BReast CAncer gene 2).
back. A number of genomic assays for According to the National Cancer Institute,
breast cancer are currently available, women with an abnormal BRCA1 or
including Oncotype DX, MammaPrint, BRCA2 gene have about a 60% risk of
Mammostrat, and other tests under being diagnosed with breast cancer
development. during their lifetimes (compared to
If the breast cancer is early-stage and about 12% for women overall). Their
hormone-receptor-positive, you and risk of ovarian cancer is also increased.
your doctor may decide that a genomic Abnormal BRCA1 or BRCA2 genes are
assay is appropriate for your situation. found in 5% to 10% of all breast cancer
The results of your genomic assay are cases in the United States.
reported separately from your
pathology report. The test results will
indicate the likelihood of the cancer
coming back based on the overall
pattern of gene activity found in the
breast cancer cells. Your doctor can use
this information to help decide whether
chemotherapy to reduce the risk of
breast cancer coming back makes sense
in your overall treatment plan.
24 25
READING YOUR
PATHOLOGY REPORT (continued)
Changes in other genes are also Finding out whether you have an
associated with breast cancer, though inherited abnormal gene requires
they are less common and don’t seem to special tests, and the results are
increase risk as much as abnormal BRCA1 separate from the results in your
and BRCA2 genes. Although abnormal pathology report. If your doctor is
BRCA1 and BRCA2 genes are considered concerned that you and your immediate
rare, there are other abnormal genes relatives may have inherited abnormal
associated with a higher-than-average BRCA1 or BRCA2 genes, he or she
risk of breast cancer that are even more may recommend that you and other
rare and haven’t been studied as much family members be tested. BRCA1 and
as the BRCA genes. These include ATM, BRCA2 tests are done using a blood or
BRIP1, CHEK2, PALB2, PTEN, TP53, and saliva sample, not a tissue sample. Your
others. You can learn more about the risks doctor or genetic counselor also may
involved with each of these abnormal order testing for other abnormal genes
genes by visiting www.breastcancer.org. if it’s determined from your personal
or family history that these tests are
needed.
26 27
READING YOUR
PATHOLOGY REPORT (continued)
28 29
READING YOUR
PATHOLOGY REPORT (continued)
MY REPORT SAYS:
The cancer is stage: (check one) j Stage IIA j Stage IIB j Stage IIIA
j Stage 0 j Stage IA j Stage IB j Stage IIIB j Stage IIIC j Stage IV
32 33
WORD LIST
Abnormal cells: Cells that do not look or BRCA2: An abnormal gene, known as
act like the healthy cells of the body. BReast CAncer gene 2, associated with a
Aggressive cancer cells: Cells that are higher risk of developing breast cancer.
fast-growing and have a tendency to Clean margins: Removed breast tissue
spread beyond the area where they around the tumor in which the outer
started. edge is free of cancer cells. Also called
Atypical ductal hyperplasia: Abnormal “negative margins.”
cells that have accumulated in a breast Close margins: Removed breast tissue
duct. The cells have increased in number around the tumor in which cancer cells
and fill almost the entire duct. The cells come near the outer edge.
can keep changing until they become Colloid (mucinous) carcinoma of the
DCIS. Atypical ductal hyperplasia can breast: A rare type of invasive breast
increase the risk of a future breast cancer that contains small pools of
cancer. mucous material.
Atypical lobular hyperplasia: Abnormal Comedo DCIS: A type of non-invasive
cells that have accumulated in a cancer that tends to grow quickly.
breast lobule. The cells have increased Comedo refers to areas of dead cancer
in number and fill almost the entire cells that build up inside the tumor—a
lobule. It’s possible for the cells to sign that the cancer cells are growing
keep changing until they become so quickly that some of the cells are not
LCIS. Atypical lobular hyperplasia can getting enough nourishment.
increase the risk of a future breast
Comedonecrosis: Clumps of dead
cancer.
cancer cells, often seen in high-grade
Axillary lymph nodes: Lymph nodes DCIS. The cells are so crowded that
under your arms. some of them do not get enough
Basal-like breast cancer: Basal-like nourishment and die.
is one of the four main molecular Cribriform carcinoma of the breast: A
subtypes of breast cancer. Basal-like less common type of invasive breast
breast cancer is hormone-receptor- cancer that invades the connective
negative and HER2-negative. Also called tissues of the breast and features holes
triple-negative breast cancer. between the cancer cells (like the holes
Benign: Not cancerous or precancerous. in Swiss cheese).
Biopsy: An operation to remove tissue Cribriform DCIS: A type of non-invasive
to check whether it’s cancer or not. breast cancer that usually grows slowly.
BRCA1: An abnormal gene, known as Cribriform DCIS features gaps between
BReast CAncer gene 1, associated with a cancer cells in the affected ducts (like
higher risk of developing breast cancer. the pattern of holes in Swiss cheese).
34 35
WORD LIST (continued)
42 43
PATHOLOGY
KEY QUESTIONS REPORT CHECKLIST
With your doctor’s help, it’s important This checklist can help you keep the
that you understand the answers to the important results from all your pathology
questions below: reports together in one place. With your
doctor’s help, fill in the answers below.
1. Is this breast cancer invasive, Then take this booklet with you when you
non-invasive, or both invasive and visit your other doctors, so they have the
non-invasive? information they need.
My pathology reports show the following cancer
2. Is this a slow-growing or a fast-growing features:
breast cancer?
1. Invasive or non-invasive:
3. Are the margins negative, close, or j invasive j non-invasive
positive? j both invasive and non-invasive
4. Are there any cancer cells present in lymph 2. Size: _______ centimeters (cm)
channels or blood vessels? 3. Grade: j grade 1 j grade 2 j grade 3
5. What do the hormone receptor tests 4. Lymphatic or vascular involvement:
show? Can I take a medicine that lowers or j present j absent
blocks the effects of estrogen? 5. Margins of resection:
j negative j close j positive
6. Which of these HER2 tests was
6. Hormone receptors:
performed on the tissue?
estrogen receptors:
• IHC (ImmunoHistoChemistry) test j positive _______% (0%-100%) j negative
or circle: Allred score 0 1 2 3 4 5 6 7 8
• FISH (Fluorescence In Situ Hybridization) test
progesterone receptors:
• SPoT-Light HER2 CISH (Subtraction j positive _______% (0%-100%) j negative
Probe Technology Chromogenic In Situ or circle: Allred score 0 1 2 3 4 5 6 7 8
Hybridization) test 7. HER2 status based on one or more of these
• Inform HER2 Dual ISH (Inform Dual In tests: IHC (ImmunoHistoChemistry) test:
Situ Hybridization) test j positive j negative j borderline
FISH (Fluorescence In Situ Hybridization) test:
7. Is the HER2 test positive, negative, or j positive (amplified) j negative (not amplified)
borderline?
SPoT-Light HER2 CISH (Subtraction Probe
8. Are any lymph nodes involved Technology Chromogenic In Situ Hybridization)
with this cancer? If so, how many? test:
j positive (amplified) j negative (not amplified)
9. What stage is the cancer? Inform HER2 Dual ISH (Inform Dual In Situ
10. Is genomic testing recommended for the Hybridization) test:
cancer? j positive (amplified) j negative (not amplified)
8. Lymph node status:
11. Am I a candidate for genetic testing? j positive (cancer found in lymph node[s])
number of lymph nodes involved: _______
12. Is any further surgery recommended
j negative (no cancer in lymph nodes)
based on these results?
9. Oncotype DX, MammaPrint, or Mammostrat
13. Which treatments are most likely to work test results: Recurrence score: _______
for this specific cancer? 10-year recurrence risk: _______
44 45
NOTES
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For more information, go to:
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