There aren't many of us in these circumstances, statistically speaking,
so staging seems to be ambiguous.  In many statements of the "TNM"
method of staging, "Tx" ("unable to assess") is used for multifocal BC.

With apologies in advance if this gets lengthy, I can only tell you how
I've come to think about it.

<grumpy>  At the time of treatment, from my perspective (5 tumors in one
breast, one in the other), I sometimes felt that they based
treatment/prognosis for multiple tumors on something they do with goat
entrails & a pentangle in the basement of the hospital! </grumpy>

Seriously:  Because doctors don't have as many study results or
deterministic rules to follow for staging BC in women like you & me, I
believe they end up relying more on professional experience.   In my
case, besides a multidisciplinary assessment that I signed up for, I
know there was some extra consultation to determine the best course of
treatment.

In many statements of the "TNM" method of staging, "Tx" ("unable to
assess") is used for multifocal BC.

Here's one thought:  Would it make any difference in your case whether
they staged from the largest tumor or the total tumor burden?  How much?

For example: In my case, my largest tumor was 3.1 cm, which would be T2.
 The whole string of 'em added together would be over 5 cm, which would
be T3.  I had one positive lymph node (N1) and no evidence of metastatic
disease (M0).  T2N1M0 would be stage 2.  T3N1M0 would be stage IIIA.

Some of my docs seem to have considered me "high" stage II, others "low"
stage IIIA.

Either way, the treatment would be pretty much the same.  (See, for
example, http://www.cancer.gov/cancerinfo/wyntk/breast .)

Clearly, with either of those stages, my treatment was going to include
Serious Chemo.  Mastectomy was recommended on the "5 tumor" side, and I
chose bilateral though I could've had lumpectomy on the other side.
They decided to do radiation on the "5 tumor" side on top of mastectomy
because of the total tumor burden.

In terms of prognosis, I can't count on the stats being predictive, as
I'm statistically unusual.  But, if I wanted to use the stat as a basis
for estimating, I might assume that my prognosis was somewhere in the
middle between generic stage II & generic stage IIIA, say around 70-75%.

(As an observation, there's one sense in which prediction from
statistics is futile anyway:  If I had a 1% prognosis, I'm not gonna end
up 1% alive.  I'm either in remission (in the lucky 1%) or not!
Similarly, if I have a 99% prognosis, I could still end up in the
*unlucky* 1%.)

In practice, my doctors prognosis estimates ranged from 60% to 80%, so I
presume they may've been thinking along the same lines I am.

Regardless, 3+ years later I'm still here, still (crossed fingers) NED,
and focusing on trying to be healthy to give myself the best odds I can,
since that's the part I *can* influence at this point.

Take care,

Ann T.
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Sue wrote:  << Do you know how they base treatment/prognosis factor with
multiple
tumors? Some say from the largest tumour, others say all the tumours
combined.As I had 3,and both lobular and ductal ,I havent been able to
find any info about this. >>

I am not sure if there is a standard way of doing such.   I had 3 different
things going on--the main tumor was a 2.5 cm invasive pleomorphic lobular
carcinoma ( arare aggressive variant of lobular).  I also had high grade DCIS
with comedo necrosis.  Then I had a separate tumor in the nipple within dermal
lymphatics (a rare presentation of inflammatory breast cancer--IBC).
Along with the above I had 9 of 12 positive axillary lymph nodes, extensive
lymphovascular invasion, was ER+ and Her2+
Pathologically, I was staged at IIb.  My oncologist gave me Herceptin
out-of-protocol, writing something to the effect that my cancer was
'different.'  Many months  later, after I had completed the first part of chemo
(4 AC) and radiation, I asked him that if I had IBC., wouldn't I have been at a
more advanced stage than IIb.  He agreed and changed my clinical reports to
read that I was at stage III.  Now, again, this was after radiation.
The radiation oncologist prescribed 25 treatments without a boost.  One
acquaintance with breast cancer, wife of a physician, had told me from the
start that when I had rads to be sure and ask for a boost.  At that time I had
no idea what a boost was or what radiation or any of the treatments involved.
The rad. onc I saw said he based my treatment on the main tumor---a 2.5 cm
invasive lobular cancer which had clear margins.  He did not take into account
the high grade dcis with comedo  necrosis or the separate tumor in the nipple
(with IBC).  That makes absolutely no sense to me.  When I asked another of the
rad. oncologists whom I saw during the treatment, since the prescribing rad.
onc. was evaluating patients, the second dr. told me that I was in the 'gray
area' as to whether or not I should get a boost.  I wasn't given the option.

It doesn't make much difference.  If you add the volumes, the largest one
dominates dramatically anyway, if you add the surface areas the small ones
still don't contribute a great deal, unlikely to tip you into the next
stage.  I can't see any justification for adding the diameters.

What they are really trying to establish is the risk that it has
metastasised, or how long it has been metastasising.  So basically one
should consider the largest tumour, presumably being the most advanced.  But
undoubtedly the others have an influence on its growth and activity, so some
adjustment is needed just for it being multifocal.  Probably the best thing
to do is to stage each tumour separately, take the worst, then add a bit for
good luck.

Tim