Understanding Your Pathology Report: A Short Primer

Your pathology report will include information your doctor will use to determine your treatment and to gauge your prognosis. If you had a biopsy before surgery, you will probably have two different reports—one from the biopsy and one from surgery. Make sure you get a copy of all your reports as they will help you understand your doctor’s recommendations. Lalit vora, MD, director of breast MRI at the City of Hope, even suggests women talk to the radiologist who did the original screening. “The radiologist should be part of your team,” he says. This can be easier said than done, however, as many radiologists prefer to work through the doctor, to reduce the risk of misunderstanding.

Your pathology test has seven sections: specimen, clinical history, clinical diagnosis, gross description, microscopic description, special tests or markers, and summary or final diagnosis.

SPECIMEN: Where the test was taken, such as left or right breast or lymph nodes. A biopsy report will not have data on lymph nodes.

CLINICAL HISTORY: A cryptic statement about your history related to this and any previous cancers. On a biopsy report, this will explain why the test was done, with a notation such a “density” or “palpable lump.” On a surgical report, it will refer to why the surgery was done, often with a simple reference to “left breast cancer.” It may also explain your surgery—“mastectomy” or “partial mastectomy,” for example.

CLINICAL DIAGNOSIS: Your specific type of cancer, such as infiltrating ductal carcinoma (a cancer that has broken through the wall of the milk duct) or ductal carcinoma in situ (the cancer remains contained in the duct).

GROSS DESCRIPTION: The size of the tumor and, for a surgical report, the size and status of the surgical margins and lymph node involvement. This includes:

•Tumor size: Tumors are measured by centimeters (cm). One cm is .394 of an inch. The smaller the better, with under 2 cm usually considered “early stage beast cancer.” 

• Lymph node involvement: The number of lymph nodes tested, and those that tested positive for cancer. A positive lymph node is one to which cancer has spread. A negative node means cancer has not spread.

• Surgical margins: This measures the amount of tissue the surgeon removed around the tumor. Ideally, this should be between 1cm and 10 cm. Clear margins mean that the cancer has not spread to the surrounding tissue.

Microscopic Description: How the cells looked under the microscope. This is most likely where you receptor status is indicated.

• Receptor status: Pathologists measure this using a system that stains the tumor after a biopsy. Different labs present results differently. Some will quantify the result; others will simply note that the cancer is positive or negative. Quantification is ideal, because the more hormones present in the cell, the less aggressive the cancer and the more likely it is to react to hormone treatment.

Some labs use a 3-point system, with a score a “0” meaning none of the cells in the biopsy sample contained receptors, and a “3” meaning most cells contained receptors. A “2” is usually considered weakly positive. Other labs may simply indicate a percentage, with 0 percent meaning no hormones were present and 100 percent meaning all cells in the sample had receptors. In this case, anything under 50 percent is usually weakly positive.

SPECIAL TESTS OF MARKERS: Two common means of assessing how rapidly the tumor is likely to grow are the Bloom-Richardson Scale and the Nottingham Histologic Score. Both readings will likely be high with HR- cancer.

• A Bloom-Richardson high grade means a fast-growing tumor; Low grade means slow-growing. The pathologist might also use the term “poorly-differentiated,” which is another way of saying aggressive.

• The Nottingham Histologic Score rates the tumor numerically based on its “mitotic” count, or how rapidly it appears to be dividing and growing. A Grade I tumor has between 1-5 points and is slow-growing. A Grade II has between 6 and 7 points and is growing at a medium pace. A Grade III is over 8 points and is rapidly growing.

SUMMARY OR FINAL DIAGNOSIS: An overview of the important aspects of your tumor.

WHAT THIS ALL MEANS: The best prognosis comes with smaller tumors that have not spread, with a low Bloom-Richardson rating or Nottingham Histologic Score. Even small HR- tumors, though, are considered aggressive.

Read more about testing and treatment for TNBC in my book, Surviving Triple-Negative Breast Cancer.

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Footsteps on The Appalachian Trail

I should have added “Hike the Appalachian Trail” to my bucket list. I don’t expect to do much of the trail, certainly not the whole thing, but I would like to at least spend a day or two on it.

I got a start this month in Falls Village Connecticut. OK, we only walked it for an hour—we had a plane to catch—but I at least set foot on the same ground that others have passed since the trail was completed in 1937. The first part of our trek was not all that scenic—we walked along Connecticut Highway 7, over the Housatonic River, down Warren Turnpike, past the Housatonic Valley Regional High School and then, finally, into the woods.

Maybe next spring we’ll go to Georgia, where the trail begins. Then, some other time, we may go to Maine, where it ends. Then we can say we went on the trail from beginning to end.

My Life In Cemeteries: Memorial Day Musings

As a kid, I spent part of every Sunday at Roselawn Cemetery in Pueblo, Colorado. We would “visit” my Prijatel and Okicich grandparents, put fresh flowers on their graves, and then wander to see my parents’ various relatives and friends. It was an oddly rewarding experience. I enjoyed hearing my Mom and Dad reminisce about their pasts and I loved the serenity of the place. Water sprinklers often chattered in the background, keeping the lawn lush and the lilac trees and snowball bushes healthy and fragrant.

My Mom taught me to walk around the graves, making sure I did not walk on top of anybody, being especially careful to avoid humps in the lawn. Occasionally, we would go to the pauper’s cemetery, where there was no lawn, the gravestones were ancient and poorly maintained, and tumbleweeds were the flowers of choice. My mother had an aunt buried there in the early 1900s, and I felt like I was walking into the Wild West when we wandered through those graves, walking gingerly to make sure we didn’t step on any humps that could be rattlesnakes.

We listened to the Slovene Hour as we drove to Roselawn, and sometimes Dad left the radio running so we could hear a favorite waltz or polka. Pueblo, Colorado, my hometown, had a healthy Slovenian population, brought there to work at the steel mill, the Colorado Fuel and Iron Corporation. My name, Prijatel, means friend in Slovene. The names on the gravestones were Slovene, Croatian, Serbian. My Dad used a racial epithet for the Serbs—a word I do not remember and am fine forgetting—inheriting a hostility toward an entire country from his parents who were Slovene immigrants. The Balkans have a long history of conflict—far longer than the recent wars between Serbia, Croatia and Bosnia in the early 1990s. That conflict lived on in the cemetery, at least in my Dad’s mind.

A few years before Dad died, I recorded a walk around the cemetery with him. I wanted a record of his memories about the people. He talked about his parents, both of whom died before I was born, and about the men he worked with at the steel mill. Dad made nails, which was a great metaphor for him—he was a strong as nails and about as sharp, in both a good and bad way. He was smart and he was acidic. As we walked over the manicured lawns in early spring, with lilacs blooming and graves festooned with irises, Dad talked in his mix of censure and compliment. “Oh, look, here’s old Frank. The old [another racial epithet, this time for Italians], I always liked him. He worked hard but he didn’t take any guff from anybody.” Farther along: “Yeah, here’s Jorge. The [another racial epithet, this time for Hispanics]. Smart, really smart. He made the rail spikes and, boy, he could fix that machine in no time flat.”

Fortunately, I did not inherit Dad’s racial perspective , but I did get the love of cemeteries. When my husband and I visited Vienna, our first stop was Zentralfriedhof, the Central Cemetery, where Beethoven, Brahms, Schubert, and Johann Strauss the elder and the younger are buried. In tiny Wrangall, Alaska, we saw one of our most intriguing cemeteries, in which graves were smothered with the special symbols of the person who had died—one was done in a nautical theme, covered with a boat wheel, nets, and a photo of the deceased in his craft.

We visited the beauty in the picture above, the Old Dutch Church and cemetery in Claverack, New York, earlier this month and it made me wonder why I love to visit cemeteries. Part of it is historical interest, to continue a link with the past, to see when people died, how long they lived, and to wonder about their lives. Partly it is because of the art involved. Gravestones can be magnificent granite monuments; outlandishly ornate mélanges of angels, crosses, and hands raised in prayer; sweetly simple rocks with loving text, or roughly rustic homemade jobs with jagged, barely visible scrapes chiseled in wood.

Everywhere, though, they are a reminder that, even though these people are gone, they left behind people who loved them and who continue to remember them. I visit the Pueblo cemetery once a year or so—my parents are now there—and I like to chat with them a bit and to spend some time with the grandparents I never knew but whom I will not forget.

Americans make their cemetery pilgramages on Memorial Day, but in Slovenia, the big celebration is on November 1—All Saints Day. For at least a block before the cemetery entrance, kiosks are set up to sell everything from the obvious to the absurd. Lots of flowers, of course, are a natural. But cotton candy? And ice cream? Our visit there was like going to a carnival. The graves were covered in flowers—fresh bouquets, plants, a mix of both—and the cemetery was packed with people, as though it were some sort of fair.

It is ironic, then, that when we tried to find my great-grandparents’ graves in Slovenia, we were told that the cemetery had moved and they were not moved with it. In Slovenia, many graves are leased, not purchased outright, so when people die or leave the country and stop paying rent, the graves they left behind revert to the church or the city.

That’s what happened to my Slovene grandparents—they moved to America and the graves of their parents simply disappeared in an abandoned churchyard. Still, my parents continued the Slovene tradition of respecting and remembering the dead and passed it on to their kids and grandkids. And so we honor other grandparents, in other graves, in other cemeteries around the world.

My Second Anniversary

I have passed the two-year mark since diagnosis.   The chances of cancer recurring decrease significantly over time, which makes every milestone important.   Hormone-negative breast cancer is most likely to recur within the first three years, so being cancer-free and healthy so far is great news, and I plan to continue in this vein.   Time to celebrate! The big party, though, will be in five years. Perhaps on Machu Picchu.

Exercise benefits younger women

Physically active premenopausal women significantly reduce their risk of breast cancer, according to research in the May 13 edition of the Journal of the National Cancer Institute. Many studies have shown an exercise benefit to postmenopausal women, but this new research shows that younger women also reduce their cancer risk. The research is part of the long-range Nurses Health Study and included 64,777 premenopausal women. Some details:

• The greatest risk reduction came from exercise between 12 and 22, with those 23 to 34 showing a slightly reduced benefit. Women over 35, in this study, gained no risk reduction, which contradicts other studies that show a benefit to lifelong exercise.

• Running 3.25 hours a week or walking 13 hours a week brings a 23 percent risk reduction.

NOTE: Hormone-negative breast cancer is most common among premenopausal women.

Exercise—the best medicine for hormone-negative

Physical activity, including moderate walks and cycling, reduces the risk of breast cancer, with the greatest benefit among women who are hormone-negative, according to a literature review of 62 studies on the effect of exercise on breast cancer risk. Other women whose gains are especially significant: non-whites, those with a family history of breast cancer, and those who have given birth to two or more children benefit the most from exercise.

The review, published in the May 13 edition of the British Journal of Sports Medicine, found that:

• In 76 percent of the studies, physically active women had a lower breast cancer risk; risk reduction was significant in 30 of the 62 studies.

• Among the studies that showed an effect, breast cancer risk was reduced by an average of 25 percent.

• Moderate activity such as walking or leisure cycling brought better odd—a 26 percent reduction—than high intensity exercise—a 22 percent reduction.

• Lifetime activity showed the greatest benefit—greater than that from activity around the time of diagnosis.

• Active postmenopausal women benefit the most. Activity over age 50 showed a greater risk reduction that activity in adolescence and early childhood.

• Thin is best, but only when associated with exercise. Women with a BMI of less than 22 had 19 percent greater risk reduction than women with a BMI above 25. (See the link on the left to compute your BMI.)

• A high BMI cuts the effect. Women with a BMI over 30, even if they are active, had no risk reduction from exercise.

Please consider a donation to Positives About Negative to keep this site going.  This work is entirely supported by readers.  Just click on the Donate button in the right of the page.  Thank you!

Read more about TNBC in my book, Surviving Triple-Negative Breast Cancer.

Carbohydrates increase hormone-negative breast cancer risk

A diet heavy in simple carbohydrates—sugar, white bread, cakes and cookies—can put a woman at risk of hormone-receptor-negative breast cancer, according to research in the American Journal of Nutrition’s May 2008 issue. French researchers studied the diets of 62,739 postmenopausal women from 1993 to 2002; 1812 of these women eventually were diagnosed with breast cancer. The researchers note that, because simple carbs are rapidly absorbed by the body, they elevate insulin levels, which can be the link to hormone-receptor-negative breast cancer. According the Centers for Disease Control, complex carbohydrates—whole grains, seeds, vegetables and most fruits—are more slowly digested and less likely to increase insulin levels.

Need a Last-Minute Mother's Day Gift? Support Cancer Information

Breastcancer.org's gift shop offers organic bouquets, Lenox vases and other goodies, with 10 percent going to the group's activities.  Or just give a donation in Mom's name.  Breastcancer.com offers comprehensive, accurate, and up-to-date  information on breast cancer.  It is an excellent site.

Finding the right genes

I am fascinated by the Human Genome Project, a wide-ranging, long-term study of DNA—and its implications on finding, treating, and avoiding diseases. Doctors say our cancer is as unique as our DNA, so I would really love to try to delve into the “why” and the “how” of my illness. I have a grandmother who died of stomach cancer—although I have long wondered if that was a euphemism for some "woman's problem" like uterine cancer. My mother died of liver cancer that started in her pancreas. My dad had a form of leukemia—often called pre-leukemia, although he died of pneumonia.

In the future, doctors speculate they will be able to customize cancer treatments based on genetic information. And drugs can be developed for specific genes. So, theoretically, our genes could be used to treat illnesses, rather than just cause them.

Still, even though I have a genetic predisposition toward cancer, other lifestyle factors such as diet and exercise are essential. Did the weight I gained in my 50s make me more susceptible?

As I said, this is a compelling medical mystery. It might be my next big project.