Treatment of locally advanced breast cancer

In their guidelines for managing locally advanced breast cancer, Tamara Shenkier and associates¹ mention the difficulty they faced in dealing with changes that were made to the tumour–node–metastasis (TNM) tumour-staging system in 2002 (Table 1). Their comment on this point needs amplification because, if anything, it understates the potential confusion caused by the introduction of a new category, stage IIIC.

Table 1

Stage IIIC is defined as applying to patients with any T category and pN3 disease (Table 2). pN3 disease in turn has 3 subcategories, the third of which (pN3c), supraclavicular node involvement, is the focus of the comments by Shenkier and associates.¹ As they state, there is now some evidence to support treating these patients as having inoperable locally advanced, rather than metastatic, disease. However, pN3a and pN3b represent types of nodal involvement (more than 10 axillary, infraclavicular and internal mammary nodes) that have little or nothing to do with operability. Most such patients would be managed in the manner that Shenkier and associates describe for operable stage IIIA disease.

Table 2

It is unfortunate that the newly introduced stage IIIC category includes 2 groups of patients for whom management strategies are quite different. Indeed, its utility as a descriptive category must be questioned, particularly in the context of management guidelines. In this setting it might have been better to use specific T and N categories, since the guideline as published appears to imply that stage IIIC is equivalent to supraclavicular node involvement.

Joseph L. Pater Queen's University Kingston, Ont.