title: Personalizing breast cancer staging by the inclusion of ER, PR, and HER2.
abstract: OBJECTIVE
  Nonanatomic factors, such as histologic grade and biomarkers, can guide breast cancer management but are not included in the current TNM staging system.
  
  
  OBJECTIVE
  To use as an example the triple-negative phenotype (TNP) defined by the absence of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor 2 (HER2) to examine whether such inclusion improves the prognostic accuracy of TNM staging for breast cancer.
  
  
  METHODS
  Women diagnosed with primary invasive ductal breast cancer from January 1, 1991, through December 31, 2008, were identified from a prospective institutional database. Excluded were patients who received neoadjuvant therapy, those whose staging information was incomplete, or those whose tumor lacked ER, PR, and HER2 data. Breast cancers were categorized by TNM stage and by the presence or absence of TNP.
  
  
  METHODS
  Overall survival at 5 years.
  
  
  RESULTS
  Database review identified 1842 consecutive eligible patients with breast cancer. When patients were stratified by TNM stage, overall survival curves for those with TNP breast cancer matched those for patients whose non-TNP breast cancer was 1 TNM stage higher. Multivariable analysis showed that TNP status was a powerful prognostic variable, and the likelihood ratio test revealed that the prognostic accuracy of the TNM staging system that incorporated TNP was superior to the current TNM staging system (P< .001). A TNM staging system that incorporated TNP reduced early-stage compression by 15%.
  
  
  CONCLUSIONS
  The internationally recognized and easily reproducible examination of ER, PR, and HER2 status exemplifies how nonanatomic factors can improve the prognostic accuracy of breast cancer staging.
authors.affiliation: Department of Surgery, Mayo Clinic Florida, Jacksonville.
authors.forename: Sanjay P
authors.initials: SP
authors.lastname: Bagaria
authors.affiliation: Department of Surgery, University of Illinois Urbana-Champaign3Carle Cancer Center, Urbana-Champaign, Illinois.
authors.forename: Partha S
authors.initials: PS
authors.lastname: Ray
authors.affiliation: Department of Biostatistics, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California.
authors.forename: Myung-Shin
authors.initials: MS
authors.lastname: Sim
authors.affiliation: Department of Biostatistics, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California.
authors.forename: Xing
authors.initials: X
authors.lastname: Ye
authors.affiliation: Department of Pathology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California.
authors.forename: Jaime M
authors.initials: JM
authors.lastname: Shamonki
authors.affiliation: Department of Molecular Oncology, Cedars-Sinai Medical Center, West Hollywood, California.
authors.forename: Xiaojiang
authors.initials: X
authors.lastname: Cui
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, West Hollywood, California.
authors.forename: Armando E
authors.initials: AE
authors.lastname: Giuliano
mesh_terms: D014408:Biomarkers, Tumor / Q000378:metabolism; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000378:metabolism / Q000401:mortality; D018270:Carcinoma, Ductal, Breast / Q000175:diagnosis* / Q000378:metabolism / Q000401:mortality; D047628:Estrogen Receptor alpha / Q000378:metabolism*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007150:Immunohistochemistry; D009367:Neoplasm Staging / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000378:metabolism*; D011980:Receptors, Progesterone / Q000378:metabolism*; D015203:Reproducibility of Results; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology
chemical_list: D014408:Biomarkers, Tumor; D047628:Estrogen Receptor alpha; D018719:Erb-b2 Receptor Tyrosine Kinases; D011980:Receptors, Progesterone; C506487:ESR1 protein, human; C508053:ERBB2 protein, human