Prognosis in Breast Cancer
Accurate prediction of prognosis is critical in guiding appropriate therapy
and its timing. The list below gives the main prognostic indicators in routine practice.
There is a very major drive at the present time to define
molecular and genetic markers to refine this process further.
Assessment of Prognosis
Tumour grade
- Higher tumour grade has an adverse influence on prognosis
- Grading is prone to being subjective and efforts need to be made to minimise this
Axillary Lymph Node Status
- Node-positivity has a major adverse influence on recurrence and survival
- The more positive nodes the worse the survival
- Axillary node sampling has been shown to give comparable prognostic information to axillary clearance
- Sentinel node biopsy may be as good as node sampling
Tumour size
- Larger tumours are more likely to metastasize than smaller tumours whatever the grade
- Evidence from screening suggests that tumours <1cm may behave differently grade for grade than larger tumours
ER status
- 80% of all cancers are ER positive
- Low grade cancers are usually ER positive, high grade cancers are more commonly negative (~30%)
- ER positive tumours have a better prognosis than ER negative tumours
Her2 Status
- Her 2 positive tumours have a poorer prognosis than Her 2 negative
- Her 2 status also influences response to other chemotherapy agents
The Nottingham Prognostic Index (NPI)
The Nottingham Prognostic Index was originally derived from clinico-pathological correlation
of a large series of symptomatic breast cancer patients. It is likely that it will need to be revised in the near future
to allow its effective application to screening patients.
The NPI is calculated as follows:
Three elements make up the final score:
Numerical Grade:
Lymph node score:
- Node negative = Score 1
- 1 = 3 Positive nodes = Score 2
- >3 Positive nodes = Score 3
Tumour size:
To calculate score ADD Numerical Grade, Lymph node score and 0.2* tumour size in Cm
Examples:
For a 10mm Grade 2 carcinoma with 2/4 nodes positive the NPI is:
4.2 - (Derived from: 2 + 2 +(0.2*1.0))
For a 24mm Grade 1 carcinoma with 4/10 nodes positive the NPI is:
4.12 - (Derived from: 1 + 3 +(0.2*2.4))
For a 15mm Grade 3 carcinoma with all nodes negative the NPI is:
4.3 - (Derived from: 3 + 1 +(0.2*1.5))