SR | Rak Dojke: ESMO Vodic za Pacijente

Транскрипт

1 Breast Rak Cancer dojke Šta je rak dojke? Dozvolite nam da odgovorimo na neka od Vaših pitanja. Serija ESMO Patient ESMO vodiča Guide za Series pacijente na based osnovu on the ESMO ESMO Smernica Clinical za Practice kliničku Guidelines praksu esmo.org

2 Rak Breast dojke cancer Rak Breast dojke Cancer ESMO An ESMO Vodič guide za pacijente for patients Informacije Patient information za pacijente based na on osnovu ESMO ESMO Clinical Smernica Practice za Guidelines kliničku praksu Ovaj This vodič guide pripremljen has been prepared je kako bi to pomogao help you, Vama, as well kao as your i Vašim friends, prijateljima, family porodici and caregivers, i negovateljima better understand da bolje razumete breast cancer rak dojke and its i njegovo treatment. lečenje. It contains U njemu information se nalaze on informacije early and o advanced ranom i uznapredovalom breast cancer, including raku dojke, the uključujući causes of the uzroke disease bolesti and i how kako it se is postavlja diagnosed, dijagnoza, up-to-date najnovije guidance smernice on the o types vrstama of treatments terapije koje that mogu may biti be dostupne available and i svim any eventualnim possible side neželjenim effects of dejstvima treatment. terapije. Medicinske The medical informacije information opisane described u ovom in this dokumentu document zasnovane is based on su the na ESMO Smernicama Clinical Practice za kliničku Guidelines praksu for za rak breast dojke, cancer, a one which su izrađene are designed kako bi to pomogle help doctors lekarima with u the postavljanju diagnosis dijagnoze and management i lečenju of ranog early i uznapredovalog and advanced raka breast dojke. cancer. ESMO All ESMO Smernice Clinical za kliničku Practice praksu Guidelines pripremili are su prepared i pregledali and vodeći reviewed stručnjaci by leading koristeći experts dokaze using iz najnovijih evidence gained kliničkih from ispitivanja, the latest istraživanja clinical trials, i stručnih research mišljenja. and expert opinion. Informacije The information koje se included nalaze in u ovom this guide vodiču is nisu not intended zamena za as savete a replacement Vašeg lekara. for your Vaš doctor s lekar poznaje advice. Vašu Your kompletnu doctor medicinsku knows your istoriju full medical i usmeriće history Vas and u pravcu will help najbolje guide terapije you regarding za Vas. the best treatment for you. Reči Words istaknute highlighted bojom in colour objašnjene are defined su u rečniku in the na glossary kraju dokumenta. at the end of the document. Ovaj This vodič guide izradili has been su i developed pregledali: and reviewed by: Predstavnici Representatives European of the Society European for Society Medical for Oncology Medical (ESMO): Oncology (ESMO): Elżbieta Senkus-Konefka, Senkus-Konefka; Fatima Cardoso, Cardoso; Jean-Yves Douillard, Douillard; Claire Claire Bramley, Bramley; Francesca Francesca Longo Longo; i Svetlana Jezdić and Svetlana Jezdic Predstavnica Representative ESMO of the Radne ESMO grupe Patient zastupnika Advocates pacijenata Working (Europa Group (Europa Donna): Donna): Tanja Tanja Španić Spanic Predstavnice European Oncology Nursing Society (EONS): Deborah Fenlon i Anita Margulies Representative of the European Oncology Nursing Society (EONS): Deborah Fenlon and Anita Margulies Prevod na srpski jezik je realizovalo Udruženje žena sa rakom dojke BISER. Zahvaljujemo European Society for Medical Oncology (ESMO) na odobrenju prava na prevod, kao i odobrenju za štampu zvaničnog prevoda, distribuciju u Srbiji i postavljanje na website Udruženja medikalnih onkologa Srbije (UMOS). Ovaj vodič je nakon zvaničnog prevoda pregledan od strane bolesnice sa rakom dojke Slađane Filipović i onkologa dr Ane Cvetanović. 2

3 ŠTA SE NALAZI WHAT S INSIDE UNUTRA ESMO Patients Guide 22 ESMO An ESMO Vodič guide za pacijente for patients 44 Rak Breast dojke: cancer: Kratak A summary pregled važnih of key information informacija 77 Šta What je rak is breast dojke? cancer? Koliko How common se često is javlja breast rak cancer? dojke? Šta What izaziva causes rak breast dojke? cancer? Kako How se is breast postavlja cancer dijagnoza diagnosed? raka dojke? Kako How će will biti my određena treatment moja be determined? terapija? Koje What su are mogućnosti the treatment lečenja options raka for dojke? breast cancer? Koje What su are mogućnosti the treatment lečenja options neinvazivnog for non-invasive raka dojke (Stage(stadijum 0) breast 0) cancer (takođe (also called se naziva in situ in carcinoma situ karcinom or DCIS)? ili DCIS)? Koje What su are mogućnosti the treatment lečenja options ranog for early invazivnog invasive raka (Stage dojke I-IIA) (stadijum breast cancer? I-IIA)? Koje What su are mogućnosti the treatment lečenja options lokalno for locally-advanced uznapredovalog (Stage raka IIB dojke III) breast cancer? (stadijum IIB III)? 30 What are the treatment options for metastatic (Stage IV) breast cancer? 30 Koje su mogućnosti lečenja metastatskog raka dojke (stadijum IV)? 33 Special populations 33 Posebne populacije 35 Clinical trials 35 Klinička ispitivanja 36 Supplementary interventions 36 Dodatne intervencije 37 What are the possible side effects of treatment? 37 Koja su moguća neželjena dejstva terapije? 58 What happens after my treatment has finished? 57 Šta se dešava nakon završetka mojeg lečenja? 60 Support groups 60 Grupe za podršku 61 References 61 Reference 63 Glossary 63 Rečnik pojmova 3

4 Rak Breast dojke cancer Rak Breast dojke: cancer: Kratak A summary pregled of važnih key information informacija Uvod Introduction u priču to o raku breast dojke cancer Rak Breast dojke cancer potiče arises iz ćelija from cells u dojkama in the breast koje su that abnormalno have grown porasle abnormally i umnožile and multiplied i tako su to formirale a lump kvržicu or tumour. ili tumor. The earliest stage of breast cancer is non-invasive disease (Stage 0), which is contained within the ducts or Najraniji lobules stadijum of the breast raka and dojke has jeste not spread neinvazivna into the bolest healthy (stadijum breast tissue 0), ograničena (also called je in na situ kanale carcinoma). ili režnjeve Invasive breast dojke i cancer nije se has proširila spread u zdravo beyond tkivo the ducts dojki (takođe or lobules se naziva into healthy i in situ breast karcinom). tissue, Invazivni or beyond rak the breast dojke se to lymph nodes proširio or van distant kanala organs ili režnjeva (Stages I u IV). zdravo tkivo dojki, ili van dojki u limfne čvorove ili udaljene organe Breast (stadijumi cancer I IV). is the most common cause of cancer-related deaths in women and occurs most frequently in postmenopausal Rak dojke je najčešći women uzrok over smrti the age povezanih of 50. Breast sa rakom cancer kod also žena occurs i najčešće in men se but javlja is very kod rare, žena making koje su up u around 1% postmenopauzi of all breast cancer starijih cases. od 50 godina. Rak dojke se takođe javlja kod muškaraca, ali je veoma redak, i predstavlja oko 1% svih slučajeva raka dojke. Diagnosis of breast cancer Dijagnoza The most raka common dojke symptoms of breast cancer are changes in the breasts such as the presence of a lump, Najčešći changes simptomi the nipple, raka discharge dojke jesu from promene the nipple u dojkama or changes kao što in the je prisustvo skin of the kvržice, breast. promene na bradavici, curenje Initial investigations iz bradavice for ili promene breast cancer kože na begin dojkama. with a physical examination, mammography and ultrasound Početna scan. In some ispitivanja cases, kada breast je u magnetic pitanju rak resonance dojke počinju imaging sa fizikalnim (MRI) pregledom, will also be mamografijom performed. If a tumour i is ultrazvučnim found, a biopsy pregledom. will be taken U nekim to assess slučajevima the cancer radi before se i any snimanje treatment dojki is planned. magnetnom rezonancom (MR). Ukoliko se otkrije tumor, radi se biopsija kako bi se procenio tip tumora pre nego što se isplanira terapija. Treatment options for breast cancer Mogućnosti The treatment lečenja of breast raka cancer dojke depends on how far advanced the cancer is (Stage 0 IV) and what type of Lečenje cancer is raka present. dojke zavisi od toga koliko je rak uznapredovao (stadijum 0 IV) i koja vrsta raka je prisutna. Operacija, Surgery, radiotherapy, radioterapija, chemotherapy, hemoterapija, endocrine hormonska therapy terapija and i ciljana targeted terapija therapy koriste are used u lečenju in the raka dojke. treatment of breast cancer. Stadijum Breast cancer raka dojke is staged se određuje according prema to tumour veličini size, tumora, involvement zahvaćenosti of lymph limfnih nodes čvorova and whether i toga da it li has se spread proširio van outside dojke the i limfnih breast and čvorova lymph u nodes druge delove to other organizma, parts of the prema body, sistemu according TNM to (T the TNM tumor, system N nodusi (T tumour, (čvorovi), M N nodes, metastaze). M metastases). Ove informacije This koriste information se kao is pomoć used u to donošenju help decide najbolje the best odluke treatment. o lečenju. Prisustvo The presence biomarkera of biomarkers uključujući including hormonske hormone receptore receptors i receptor and a receptor pod nazivom called HER2 HER2 takođe also help pomažu to u određivanju determine what koji type će se of tip therapy terapije is davati. given. Neinvazivni Early stage rak non-invasive dojke u ranom breast stadijumu cancer Biological Biološko testiranje testing of tumora the tumour Pacijentima Patients with čija Stage je bolest 0 disease u stadijumu will usually 0 obično have the će tumour se tumor removed ukloniti by poštednom breast-conserving operacijom surgery dojke ili or mastektomijom. mastectomy. Radiotherapy Radioterapija is given se daje after nakon breast-conserving poštedne operacije surgery dojke but ali is obično not usually nije potrebna needed after nakon mastektomije. mastectomy. Most Većina patients pacijenata with oestrogen sa rakom sa receptor pozitivnim (ER) estrogenskim positive cancer receptorima will be given (ER) endocrine primaće endokrinu therapy after terapiju surgery nakon and radiotherapy. operacije i radioterapiju. Endocrine Hormonska therapy is given terapija to decrease daje the kako risk bi of se recurrence smanjio rizik od (the recidiva cancer (ponovne coming back), pojave as raka) well as kao prevention i da bi se of sprečio new cancers novi rak in i both u preostalom the remaining delu dojke and contralateral i u drugoj dojci. breast. 4

5 ESMO Vodič Patients za pacijente Guide Invazivni Early stage rak invasive dojke u ranom breast stadijumu cancer Pacijenti Patients with sa bolešću Stage I IIA stadijuma disease I will IIA usually obično be će treated biti hirurški with surgery lečeni kako to remove bi se the uklonio tumour tumor and i any svi affected zahvaćeni lymph limfni čvorovi. nodes. Breast-conserving Poštedna operacija surgery dojke uvek is always je praćena followed radioterapijom. by radiotherapy. Većina Most pacijenata patients will će then nakon receive toga primati adjuvantnu therapy terapiju with sa one jednim or a combination ili kombinacijom of systemic sistemskih treatments, lekova, depending u zavisnosti on the od vrste type of raka. cancer present. Neke Some pacijentkinje, patients, particularly posebno those one sa with većim larger tumorima, tumours, možda may receive će primati preoperative neoadjuvantnu neoadjuvant sistemsku systemic terapiju pre operacije therapy to kako shrink bi se the smanjio tumour tumor and improve i povećala the verovatnoća likelihood of uspešnog successful hirurškog surgical uklanjanja removal of tumora, the tumour, ili smanjio or to obim decrease operacije the extent (čime of se surgery takođe (which može postići can also i bolji achieve kozmetički a better rezultat). cosmetic result). Standardni The standard režimi chemotherapy hemoterapije regimens u slučaju in ranog early breast raka dojke cancer obično usually sadrže contain antracikline anthracyclines (npr. epirubicin (e.g. ili doksorubicin) epirubicin or doxorubicin) odnosno taksane and/or (npr. taxanes paklitaksel (e.g. paclitaxel ili docetaksel), or docetaxel), koji se daju given sekvencijalno. sequentially. Pacijenti Patients with sa ER ER pozitivnom positive disease bolešću will primaće receive endokrinu endocrine terapiju. therapy. Kod In premenopausal žena u predmenopauzi women to this je is najčešće usually tamoksifen tamoxifen alone sam or ili u in kombinaciji combination sa with lekovima drugs koji that potiskuju suppress stvaranje the ovarian estrogena production u jajnicima of oestrogen (a nazivaju (called se analozi gonadotropin-releasing gonadotropin-oslobađajućeg hormone analogues). hormona). Suppression Smanjenje funkcije of ovarian jajnika function takođe may se also može be sprovesti used with sa inhibitorima aromatase inhibitors. aromataze. In Kod postmenopausal žena u postmenopauzi women, aromatase koriste inhibitori inhibitors aromataze or tamoxifen ili tamoksifen, are used, either bilo pojedinačno alone or sequentially. ili sekvencijalno. Pacijenti Patients with sa HER2 HER2 pozitivnim positive rakom breast dojke cancer obično will usually primaju receive anti-her2 the anti-her2 lek trastuzumab drug trastuzumab hemoterapiju. as well Kod as nekih chemotherapy. pacijenata može In some se dodati patients, i pertuzumab. this may also Neratinib be combined je novi with anti-her2 pertuzumab. lek koji Neratinib takođe može is a new da se anti- koristi za HER2 lečenje agent HER2 that pozitivne may also bolesti. be used to treat HER2 positive disease. Lokalno uznapredovali i metastatski rak dojke (takođe se naziva i uznapredovali rak dojke) Locally-advanced and metastatic breast cancer (also called advanced breast cancer) Većina pacijenata čiji je rak dojke klasifikovan kao rak stadijuma IIB III primaće neoadjuvantnu terapiju pre Most patients whose breast cancer has been classed as Stage IIB III will receive neoadjuvant therapy operacije. U zavisnosti od vrste raka dojke, to može da bude jedno od ili kombinacija sledećeg: hemoterapija, before surgery is performed. Depending on the type of breast cancer, this can include one or a combination hormonska terapija, anti-her2 terapija i radioterapija. of chemotherapy, endocrine therapy, anti-her2 therapy and radiotherapy. Pacijentima sa rakom dojke stadijuma IV obično se neće raditi operacija, ali se može razmatrati u nekim Patients with Stage IV breast cancer will not usually be treated with surgery, but it may be discussed in some cases. slučajevima. ER positive advanced disease is usually treated with endocrine therapy using aromatase inhibitors, ER pozitivna uznapredovala bolest obično se leči endokrinom terapijom uz primenu inhibitora aromataze, tamoxifen or fulvestrant. In some cases, these drugs are combined with targeted therapies such tamoksifena ili fulvestranta. U nekim slučajevima, ti lekovi se kombinuju sa ciljanim terapijama kao što as cyclin-dependent kinase 4/6 (CDK4/6) inhibitors (palbociclib, ribociclib and abemaciclib) or su inhibitori ciklin-zavisnih kinaza 4/6 (CDK4/6) (palbociklib, ribociklib i abemaciklib) ili inhibitori mechanistic target of rapamycin (mtor) inhibitors (everolimus) to improve outcomes. mehanističkog cilja rapamicina (mtor) (everolimus) kako bi se unapredili ishodi lečenja. For ER negative tumours and for ER positive tumours that have stopped responding to endocrine Za ER negativne tumore i za ER pozitivne tumore koji su prestali da reaguju na endokrinu terapiju obično therapy, chemotherapy with capecitabine, vinorelbine or eribulin is usually used. A taxane or an se koristi hemoterapija sa kapecitabinom, vinorelbinom ili eribulinom. Taksan ili antraciklin se takođe anthracycline may also be used in some patients. mogu koristiti kod nekih pacijenata. HER2-positive advanced disease is usually treated with trastuzumab and pertuzumab in combination HER2-pozitivna uznapredovala bolest obično se leči trastuzumabom i pertuzumabom u kombinaciji sa with chemotherapy (docetaxel, paclitaxel, vinorelbine or capecitabine). Further-line treatments hemoterapijom (docetaksel, paklitaksel, vinorelbin ili kapecitabin). Dalje linije terapije obuhvataju include trastuzumab emtansine (T-DM1), trastuzumab in combination with lapatinib, lapatinib in trastuzumab emtanzin (T-DM1), trastuzumab u kombinaciji sa lapatinibom, lapatinib u kombinaciji sa combination with capecitabine or trastuzumab in combination with other chemotherapy agents. kapecitabinom ili trastuzumab u kombinaciji sa drugim hemoterapijskim lekovima. Bevacizumab can be combined with chemotherapy but provides only a small benefit with no impact on Bevacizumab se može kombinovati sa hemoterapijom ali ima veoma malu korist bez ikakvog uticaja na survival, and is therefore rarely used. Olaparib and talazoparib are new targeted therapies that may be preživljavanje i stoga se retko koristi. Olaparib i talazoparib su nove ciljane terapije koje se mogu koristiti za used to treat BRCA-associated advanced breast cancer (i.e. hereditary advanced breast cancer). lečenje uznapredovalog raka dojke povezanog sa BRCA (tj. naslednog uznapredovalog raka dojke). 5

6 Rak Breast dojke cancer Kontrola Follow-up ranog of early raka breast dojke cancer nakon terapije after treatment Lekar You will će usually Vas obično be seen pregledati by your svaka doctor 3-4 every meseca 3-4 months tokom for prve the dve first godine two years nakon after završetka finishing terapije, treatment, svakih every 6-8 meseci 6-8 months u periodu from years od do 5. and godine, once a year nakon thereafter. toga jednom godišnje. Takođe You will će also te raditi have a mamografiju mammography svake every godine, year, a and neki some pacijenti patients će biti will snimani also have magnetnom regular MRI rezonancom or ili ultrasound ultrazvukom. scans. Pacijentima Patients taking koji uzimaju endocrine endokrinu therapy terapiju will have radiće regular se redovne assessments kontrole to monitor u cilju praćenja the side neželjenih effects of the dejstava treatment. terapije. 6

7 ESMO Vodič Patients za pacijente Guide Šta What je is rak breast dojke? cancer? Rak Breast dojke cancer je rak is a koji cancer se stvara that forms u tkivima in the dojke tissues obično of the u breast kanalima usually (tubusima in the koji ducts prenose (tubes mleko that carry do bradavice) milk to the ili režnjevima nipple) or lobules (žlezdama (glands koje that stvaraju make mleko). milk). It Javlja occurs se in i both kod muškaraca men and women, i kod žena, although iako male je rak breast dojke cancer kod muškaraca is rare. redak. Zid Chest grudnog wall koša Rebro Rib Mišići Chest zida wall grudnog muscles koša Režnjevi Lobules (lobule) Areola Bradavica Nipple Kanal Duct (dukt) Fatty Masno tissue tkivo Koža Skin Anatomija Anatomy of ženske the female dojke. breast. Koje What su are različite the different vrste raka types dojke? of breast cancer? Rak Breast dojke cancer se može can be kategorisati categorised prema by whether tome da it li is je non-invasive neinvazivan ili or invazivan: invasive: Neinvazivni Non-invasive rak breast dojke cancer (in situ) (in situ) Duktalni Ductal carcinoma karcinom in situ (DCIS) predstavlja is a pre-malignant predmalignu lesion leziju it is to not još yet nije cancer, rak, ali but može can se progress razviti i to postati become invazivni an oblik invasive raka form dojke. of Kada breast je u cancer. pitanju In ta this vrsta type raka, of cancer, ćelije raka the nalaze cancer se cells u kanalima are in the ducts dojki, ali of se the još breast nisu but proširili have u not zdravo tkivo spread dojke. into the healthy breast tissue. Lobularna neoplasia neoplazma (previously (prethodno called lobularni lobular karcinom carcinoma situ) in situ) javlja is se when kada there postoje are promene changes in u ćelijama the cells oko lining režnjeva, što the ukazuje lobules, na which to da indicate postoji povećan that there rizik is an od increased pojave raka risk dojke of developing u budućnosti. breast Lobularna cancer neoplazma in the future. zapravo Lobular nije rak dojke, neoplasia pa iako is not će actually žene sa breast lobularnom cancer, neoplazimom and although redovno women biti with kontrolisane, lobular neoplasia kod većine will njih have se regular neće razviti check-ups, rak dojke. most will not develop breast cancer. Invazivni rak dojke Invazivni Invasive breast rak dojke cancer je naziv za rak koji se proširio van kanala (invazivni duktalni rak dojke) ili režnjeva (invazivni lobularni Invasive rak breast dojke). cancer Oni se is the dalje name mogu given klasifikovati to a cancer prema that histologiji; has spread recimo, outside tubularni, the ducts mukozni, (invasive medularni ductal i breast papilarni tumori cancer) dojke or lobules predstavljaju (invasive ređe lobular podtipove breast raka cancer). dojke. These can be further classified by their histology; for example, tubular, mucinous, medullary and papillary breast tumours are rarer subtypes of breast cancer. Rak dojke se kategorizuje i prema tome koliko je bolest uznapredovala: Breast cancer is also categorised by how advanced the disease is: 7

8 Rak Breast dojke cancer Rani Early rak breast dojke cancer Rak Breast dojke cancer se opisuje described kao rani as ukoliko early if se the tumor tumour nije has proširio not spread van dojke beyond ili pazušnih the breast limfnih or axillary čvorova lymph (poznat nodes i kao rak (also dojke known stadijuma as Stage 0 IIA). 0 Ovaj breast tip cancer). raka obično These može cancers operisati are usually i primarno operable se često and the leči primary operacijom treatment kako bi is se often uklonio, surgery iako to remove mnogi the pacijenti cancer, pre although operacije many takođe patients primaju also i neoadjuvantnu have preoperative sistemsku neoadjuvant terapiju. systemic therapy. Lokalno uznapredovali rak dojke Locally-advanced breast cancer Rak Breast dojke cancer se smatra is locally-advanced lokalno uznapredovalim if it has spread ukoliko from se proširio the breast iz dojke to nearby u okolno tissue tkivo or lymph ili limfne nodes čvorove (Stage (stadijum IIB IIB III). III). In Kod the vast velike majority većine of pacijenata patients, lečenje treatment lokalno for locally-advanced uznapredovalog raka breast dojke cancer počinje starts sistemskim with systemic lekovima. therapies. U Depending zavisnosti on od how toga far koliko the cancer se rak proširio, has spread, lokalno locally-advanced uznapredovali tumori tumours mogu may biti be either ili operabilni operable ili inoperabilni or inoperable (u tom slučaju (in which se case operacija surgery ipak may može still izvesti be performed ukoliko se if tumor the tumour smanji shrinks nakon after sistemskog systemic lečenja). treatment). Metastatski Metastatic breast rak dojke cancer Rak Breast dojke cancer se opisuje described kao metastatski metastatic kada when se proširio it has spread u druge to delove other organizma, parts of the kao body, što such kosti, as the jetra bones, ili pluća liver (stadijum or lungs (also IV). Tumori called Stage na udaljenim IV). Tumours mestima at nazivaju distant sites se metastaze. are called metastases. Metastatski rak Metastatic dojke nije breast izlečiv, cancer ali se is može not lečiti. curable but is treatable. Uznapredovali rak dojke Advanced breast cancer Uznapredovali Advanced breast rak cancer dojke je is termin a term koji used se to koristi describe za opisivanje both locally-advanced i lokalno uznapredovalog inoperable inoperabilnog breast cancer raka and dojke i metastatskog metastatic breast raka cancer. dojke. Podtipovi na osnovu statusa hormonskih receptora i HER2 ekspresije gena Subtypes based on hormone receptor status and HER2 gene expression Rast nekih tumora podstiču hormoni estrogen i progesteron. Važno je otkriti da li je tumor estrogen receptor The growth (ER) of some ili progesteron tumours is receptor stimulated (PgR) by the pozitivan hormones ili negativan oestrogen jer tumori and progesterone. sa visokim nivoom It is important hormonskih to find out whether receptora a tumour mogu da is oestrogen se leče lekovima receptor koji smanjuju (ER) or progesterone isporuku hormona receptor u tumor. (PgR) positive or negative, as tumours with a high level of hormone receptors can be treated with drugs that reduce the supply HER2 of je hormone takođe receptor to the tumour. koji učestvuje u rastu ćelija i prisutan je u oko 20% karcinoma dojke. Tumori HER2 is koji also imaju a receptor visok nivo that HER2 is involved mogu in se the lečiti growth anti-her2 of cells lekovima. and is present in about 20% of breast cancers. Tumori Tumours koji that nemaju have a ER, high PgR level ili visoke of HER2 nivoe can HER2 be treated opisani with su anti-her2 kao trostruko drugs. negativni tumori. Tumori Tumours se that mogu don t klasifikovati have ER, u PgR podtipove or high na levels osnovu of HER2 statusa are hormona described i HER2 as triple-negative receptora: luminalni tumours. A tip (ER i PgR pozitivni, Tumours HER2 can be negativni classified tumori), into subtypes luminalni based B tip on (ER hormonal odnosno and PgR HER2 pozitivni, receptor HER2 status pozitivni as ili follows: negativni luminal tumori), HER2 A-like sa (ER preteranom and PgR positive, ekspresijom HER2 (ER negative i PgR negativni, tumours), HER2 luminal pozitivni B-like tumori) (ER and/or i bazalni PgR tip positive, (trostruko HER2 negativni positive tumori). or negative tumours), HER2 overexpressing (ER and PgR negative, HER2 positive tumours) and basal-like Dodatne (triple-negative informacije tumours). o uticaju tih podtipova na lečenje raka dojke biće date kasnije u ovom vodiču u odeljku: Kako će Further biti određena information moja regarding terapija?. the impact of these subtypes on breast cancer treatment will be explained later in this guide in the section: How will my treatment be determined?. 8

9 ESMO Vodič Patients za pacijente Guide Koji What su are simptomi the symptoms raka dojke? of breast cancer? Simptomi Symptoms raka of breast dojke obuhvataju: cancer include: Kvržicu A lump in u dojci the breast Promenu Change in veličine the size ili or oblika shape dojke of the breast Udubljenja Dimpling of na the koži skin ili or zadebljanje thickening in tkiva the dojke breast tissue Uvlačenje An inverted bradavice nipple Osip Rash na on bradavici the nipple Curenje Discharge iz from bradavice the nipple Otok Swelling ili kvržica or a lump u pazuhu in the armpit Bol Pain ili or nelagodnost discomfort in u dojkama the breast koji that ne doesn t prolaze go away Crvenilo Skin redness kože Zadebljanje Skin thickening kože Ukoliko You should prepoznate see your bilo doctor koji if od you ovih experience simptoma, any trebalo of these bi symptoms. da odete na However, pregled it kod is important lekara. Ipak, to remember važno je imati that these na umu symptoms da te simptome may also be mogu caused da by izazovu other i conditions. druga stanja. Određeni Certain symptoms simptomi may mogu indicate da ukažu the na presence prisustvo of metastaza metastases na for primer, example, kvržica a lump ili otok or swelling u pazuhu, under oko grudne the armpit, kosti in ili the ključne breast kosti bone može or collar da bude bone simptom area may metastaza be a symptom u limfnim of lymph čvorovima. node metastases. Bol u kostima Pain ili kosti koje su sklone prelomima mogu da ukažu na in a bone or a bone prone to fracture might suggest metastaze u kostima, a metastaze na plućima mogu bone metastases, and lung metastases may cause da izazovu simptome infekcija u grudima, uporni kašalj symptoms of ongoing chest infections, persistent cough i gubitak daha. Važno je da ne budete uznemireni zbog and breathlessness. It s important not to be alarmed by ovih simptoma jer oni ne moraju da znače da imate metastaze; these symptoms ipak, as o they svim don t nedoumicama necessarily treba mean da that porazgovarate you have metastases; sa lekarom. however, you should discuss any concerns with your doctor. Sve Any promene changes u to dojkama your breasts treba should da be prijavite reported svom to your lekaru doctor jer as one they mogu may be da a symptom budu simptom of breast raka cancer dojke 9

10 Rak Breast dojke cancer Koliko How common se često is javlja breast rak cancer? dojke? Rak Breast dojke cancer je najčešći is most kod common žena starijih in women od 50 over godina, 50, ali but se may može also javiti occur i kod in young mlađih women žena. Rak Breast dojke cancer je vodeći is a leading uzrok smrti cause povezanih of cancer-related sa rakom deaths kod žena, in women, sa skoro with 1,7 almost miliona 1.7 novih million slučajeva cases svake diagnosed godine per i više year od and pola more miliona than half smrti a svake million godine deaths (Ferlay every et year al. 2013). (Ferlay U et razvijenim al. 2013). In zemljama developed rak countries, dojke se javlja 1 in every kod 1 8 od women 8 žena. U will Evropi develop dijagnoza breast raka cancer dojke in their se postavlja lifetime. svaka In Europe, 2 minuta, there a is do a smrti breast usled cancer raka diagnosis dojke dolazi every svakih 2 minutes 6 minuta. and Rak dojke najviše pogađa starije žene, a većina pacijenata je starija od 50 godina kada im se postavi dijagnoza, iako se a death due to breast cancer every 6 minutes. Breast cancer mostly affects older women, with the majority of oko 1 od 5 slučajeva raka dojke dijagnostikuje pre 50. godine. Rak dojke kod muškaraca je redak i predstavlja oko patients being over the age of 50 when diagnosed, although around 1 in 5 breast cancers are diagnosed before 1% svih slučajeva raka dojke. the age of 50. Breast cancer in men is rare and makes up around 1% of breast cancer cases. Stope incidence raka dojke kod žena variraju od regiona do regiona i najviše su u Zapadnoj Evropi i Sjedinjenim Female breast cancer incidence rates vary widely between regions, with the highest incidence rates in Western Američkim Državama, a najniže u Africi i Aziji. Visoka incidenca raka dojke u razvijenijim zemljama odražava prisustvo Europe and the United States, and the lowest in Africa and Asia. Higher breast cancer incidence in more većeg broja faktora rizika za rak dojke u tim zemljama (Torre et al. 2016). developed countries reflects the presence of more breast cancer risk factors in these countries (Torre et al. 2016). Ipak, incidenca raka dojke u zemljama u razvoju sve brže raste. Uprkos visokim stopama incidence, broj smrti usled However, the incidence of breast cancer in developing countries is rapidly increasing. Despite higher incidence raka dojke u većini zapadnih zemalja se smanjuje poslednjih godina zbog poboljšanog lečenja i ranijeg otkrivanja, ali se rates, znatno deaths povećava due to breast u zemljama cancer u in razvoju. most Western U razvijenim countries zemljama have oko decreased 10 15% in recent pacijenata years ima due uznapredovalu to improved bolest u treatment trenutku and postavljanja earlier detection, dijagnoze, but u have poređenju substantially sa 40 90% increased u zemljama in developing u razvoju countries. (Balogun In and developed Formenti 2015). countries, around 10 15% of patients have advanced disease at diagnosis, compared with 40 90% in developing countries (Balogun and Formenti 2015). Broj Deaths smrtnih due to slučajeva breast cancer kao posledica have decreased raka dojke u zapadnim in Western zemljama countries smanjuje due to earlier se usled detection poboljšanog lečenja and improved i ranijeg treatment otkrivanja. 10

11 ESMO Vodič Patients za pacijente Guide Na The mapi su shows prikazani estimated procenjeni numbers brojevi of new novih cases slučajeva of breast raka cancer dojke diagnosed dijagnostikovani in (the godine most (najnoviji recent statistics dostupni available) statistički per podaci) 100,000 na people of ljudi each u region s populaciji population svakog regiona (Ferlay (Ferlay et al. 2013). et al. 2013). NORTHERN SEVERNA AMERIKA AMERICA 91.6 CENTRALNA AND I ISTOČNA WESTERN ZAPADNA EUROPE EVROPA EVROPA EASTERN EUROPE EASTERN ISTOČNA AZIJA ASIA 27.0 CENTRALNA AMERICA AMERIKA 32.8 JUŽNA SOUTHERN EVROPA EUROPE 74.5 SEVERNA NORTHERN EVROPA EUROPE 89.4 MELANESIA MELANEZIJA SOUTH JUGOISTOČNA EASTERN AZIJA ASIA CARRIBEAN KARIBI 46.1 SOUTH JUŽNA AMERICA AMERIKA 52.1 WESTERN ZAPADNA AFRICA AFRIKA 38.6 MIDDLE SREDNJA AFRICA AFRIKA 26.8 SOUTHERN JUŽNA AFRIKA AFRICA 38.9 WESTERN ZAPADNA AZIJA ASIA 42.8 EASTERN ISTOČNA AFRICA AFRIKA 30.4 SEVERNA NORTHERN AFRIKA AFRICA 43.2 SOUTH JUŽNA CENTRALNA AZIJA ASIA 28.2 AUSTRALIA/ AUSTRALIJA/ NEW NOVI ZEALAND ZELAND 85.8 MICRONESIA/ MIKRONEZIJA/ POLYNESIA POLINEZIJA

12 Rak Breast dojke cancer Šta What izaziva causes rak breast dojke? cancer? Nije The poznat precise tačan cause uzrok of breast raka cancer dojke, ali is unknown, je otkriveno but nekoliko several faktora risk factors rizika for za pojavu developing bolesti. the Važno disease je zapamtiti have been da postojanje identified. faktora It is important rizika povećava to remember rizik od that pojave having raka, a risk ali factor ne znači increases da ćete the sigurno risk of dobiti cancer rak. developing Isto tako, odsustvo but it does faktora not mean rizika that ne you znači will da definitely sigurno get nećete cancer. dobiti Likewise, rak. not having a risk factor does not mean that you definitely won t get cancer. Najvažniji Most important faktori risk rizika factors Female Ženski pol gender Exposure Izloženost to ionising jonizujućem radiation zračenju Increasing Starije osobe age Having Žene fewer sa children manjim brojem dece Genetic predisposition (family history History Istorija of atypical atipične Genetska predispozicija (porodična istorija hyperplasia hiperplazije Gojaznost or ili mutacije mutations u in određenim certain genes) genima) Obesity Alkohol Exposure Izloženost to estrogenima oestrogens Alcohol Postoje There are različiti various faktori risk factors rizika povezani associated sa pojavom with developing raka dojke, breast iako cancer se većina although faktora most ne of odnosi the factors na svaku will ženu not apply kod koje to every se javi bolest. woman who develops the disease. A woman s family history of breast cancer Istorija raka dojke u porodici žene važan je faktor is an important factor that determines her risk koji određuje njen rizik za pojavu bolesti of developing the disease Porodična Family history istorija plays igra a važnu very important ulogu u tome role da in whether li će se kod or not neke a woman žene pojaviti will develop rak dojke breast ili ne. cancer. Žene Women koje u porodici, with a first-degree u prvom kolenu relative (roditelj, (parent, sestra/brat sibling or ili child) dete) imaju with breast srodnika cancer sa rakom have twice dojke, the imaju risk dva of developing puta veći rizik breast od cancer pojave compared raka dojke with od žena a woman koje nemaju with no takvu such porodičnu family history. istoriju. The Rizik risk se is increased povećava 3 3-fold puta if ukoliko that je dijagnoza raka dojke tom srodniku postavljena relative was diagnosed with breast cancer before pre menopauze (Collaborative Group on Hormonal the menopause (Collaborative Group on Hormonal Factors in Breast Cancer 2001). Factors in Breast Cancer 2001). 12

13 ESMO Vodič Patients za pacijente Guide Mutacija BRCA mutation BRCA Oko Around 5% 5% slučajeva of breast raka cancers dojke i and do 25% up to slučajeva 25% of familial raka dojke breast u porodici cancer izaziva cases are mutacija caused BRCA1 by a BRCA1 ili BRCA2 or BRCA2 (Skol et mutation al. 2016). Žena (Skol et koja al. 2016). je nosilac A woman mutacije carrying BRCA1 a BRCA1 ima doživotni mutation rizik has od a 65 95% za lifetime pojavu risk raka of dojke, breast a cancer, smatra se and da more se više than od 90% of slučajeva hereditary naslednog breast and raka ovarian dojke cancers i jajnika javlja are thought usled mutacije to be due u to BRCA1 a mutation ili BRCA2 in BRCA1 (Paluch- or Shimon BRCA2 et (Paluch-Shimon al. 2016). et al. 2016). Lekar A doctor će uputiti will refer ženu a woman na testiranje for BRCA1 za mutaciju and BRCA2 BRCA1 i mutation BRCA2 na testing osnovu based njene on porodične her family istorije history i etničkog and porekla. ethnic background. Ukoliko se otkrije If she da is found ona nosi to be mutaciju carrying a u mutation jednom ili in oba one BRCA or both gena, of these biće genes, joj ponuđeno she will savetovanje be offered counselling tokom koga during će joj biti which predočene her options mogućnosti for za reducing smanjenje the risk rizika of od developing pojave raka breast dojke, cancer, kao što such as su preventivna dvostruka mastektomija odnosno a preventative double mastectomy and/or salpingooophorectomy (removal of the ovaries and fallopian salpingo-ooforektomija (uklanjanje jajnika i jajovoda) (Paluch-Shimon et al. 2016). tubes), will be discussed (Paluch-Shimon et al. 2016). Žene Women koje who imaju test pozitivan positive test for BRCA1/2 mutacije mutation BRCA1/2 biće will be pažljivo monitored praćene carefully i biće im and ponuđene offered riskreduction measures mere za smanjenje rizika Ženama Women who za koje are se found otkrije to be da carrying su nosioci a mutacije BRCA mutation BRCA i and koje do se not ne opt odluče for risk-reducing za operaciju kojom surgery se should smanjuje rizik treba be offered ponuditi a clinical kliničke examination preglede svakih every meseci months od from 25. the godine age of (ukoliko 25 (or je 10 dijagnoza years before raka the dojke youngest u porodici bila pre 25.godine breast cancer onda diagnosis kontrole počinju the family, 10 godina if earlier), pre najmlađe magnetic dijagnoze resonance raka imaging dojke u porodici), (MRI) every snimanje 12 months magnetnom and rezonancom mammography (MR) every svakih months meseci from i mamografiju the age of 30 (Paluch-Shimon svakih 12 meseci et al. 2016). od 30. godine (Paluch-Shimon et al. 2016). 13

14 Rak Breast dojke cancer Kako How is se breast postavlja cancer dijagnoza diagnosed? raka dojke? Dijagnoza Breast cancer raka is dojke usually obično diagnosed postavlja by clinical kliničkim examination, pregledom, imaging snimanjem and biopsy. i biopsijom. Klinički Clinical pregled examination Vaš Your lekar doctor će will pregledati examine Vaše your dojke breasts i limfne and lymph čvorove. On nodes. će Vam He/she takođe will postaviti also ask pitanja you about o tome any da family li je u Vašoj history porodici of breast bilo cancer slučajeva and raka whether dojke you i da have li ste reached ušli u menopause menopauzu or ili not. ne. He/she Možda će may uzeti also i uzorak take a blood krvi za rutinske sample for analize routine krvi. blood Ukoliko tests. postoji If there sumnja is a suspicion da imate tumor dojke, lekar će Vam možda zakazati snimanje. that you may have a breast tumour, he/she may arrange for you to have an imaging scan. Snimanje Tehnike Imaging snimanja koje se primenjuju kod žena kod kojih postoji Imaging sumnja techniques na rak used dojke for obuhvataju women in mamografiju, whom breast ultrazvuk cancer is suspected odnosno magnetnu include mammography, rezonancu (MR) ultrasound : and/or MRI scan: Mamografija: Mammography: Mamografija Mammography predstavlja is a type vrstu rendgena of low-dose sa x-ray malim that dozama looks zračenja for early breast pomoću koga se cancers. traži rani Your rak breasts dojke. will Svaka each od be Vaših placed dojki on biće the stavljena x-ray machine na rendgen and pressed aparat between i pritisnuta two između plates dve to produce ploče kako a clear bi se image. dobio If jasan the mammography snimak. Ukoliko mamografski screening shows skrining anything pokaže suspicious nešto sumnjivo in your u tkivu breast Vaše tissue, dojke, your Vaš doctor lekar will će to investigate dalje ispitati. further. Ultrazvuk: Ultrasound Ultrazvuk scan: Ultrasound koristi zvučne uses talase highfrequency sound kako bi waves stvorio to sliku create unutrašnjosti an image of the visoke frekvencije Vašeg inside organizma. of your body. U ispitivanjima In investigations koja for se vrše breast kako bi cancer, se otkrio a hand-held rak dojke, ultrasound ručni ultrazvučni device lets uređaj the omogućava lekaru da pregleda Vaše grudi i limfne doctor examine your breasts and the lymph čvorove u Vašem pazuhu. Ultrazvuk može da nodes in your armpit. The ultrasound can show pokaže da li je kvržica čvrsta, ili se radi o cisti whether a lump is solid or is a fluid-filled cyst. ispunjenoj tečnošću. MRI scan: MRI uses magnetic fields and radio Magnetna rezonanca: Magnetna rezonanca waves to produce detailed images of the inside koristi magnetna polja i radio-talase za pravljenje of your body. An MRI scanner is usually a large slika unutrašnjosti organizma. MR skener obično je velika tube that cev contains u kojoj se powerful nalaze jaki magnets. magneti. You Vi lie ležite u toj inside cevi the tokom tube snimanja during the koje scan, traje which takes minuta. Iako ovakvi minutes. pregledi Although ne predstavljaju these are not deo used rutinskih as ispitivanja, part of routine pregled investigations, magnetnom an rezonancom MRI scan might može be used in koristiti certain u circumstances, određenim okolnostima, for example recimo in kod patients pacijenata with a sa family porodičnom history of istorijom breast cancer, raka dojke, BRCA mutacijama mutations, BRCA, breast implantima implants, lobular u grudima, cancers, lobularnim if there rakom, is a suspicion ukoliko of postoji multiple sumnja tumours, na višestruke or if the results tumore of ili other ukoliko imaging rezultati techniques drugih tehnika are inconclusive snimanja ne (Cardoso dovode et do al. zaključka 2018 [in press]). (Cardoso MRI et is al. also 2018 used [u štampi]). to see Magnetna if a tumour rezonanca has responded se može to treatment, koristiti kako and bi to se plan videlo further da li therapy. je tumor reagovao na terapiju, kao i za planiranje daljeg lečenja. 14

15 ESMO Vodič Patients za pacijente Guide Biopsija Biopsy Biopsija A tumour tumora biopsy daje gives lekaru the doctor informacije information o vrsti raka about dojke the type koja of je breast prisutna cancer i pomaže present u planiranju and lečenja helps to plan treatment Kada When se breast javi sumnja cancer na is suspected, rak dojke, uzima a biopsy se biopsija is taken iz from tumora the tumour pre nego before što se any isplanira treatment lečenje is planned (Cardoso (Cardoso et al [u et štampi]). al [in Biopsija press]). The se uzima biopsy pomoću is taken igle, with obično a needle, vođene usually ultrazvukom guided by (a ultrasound nekada se (or koristi sometimes i mamografija using ili MR, mammography ukoliko tumor or nije MRI, vidljiv if the na tumour ultrazvuku) is not kako visible bismo on ultrasound) bili sigurni da to je make biopsija sure the uzeta biopsy iz odgovarajuće is taken from oblasti u dojci. the correct Biopsija area daje in the lekarima breast. važne The biopsy informacije gives o the vrsti doctors raka dojke. important information on the type of breast cancer. Istovremeno At the same time sa biopsijom, as the biopsy, u tumor a marker se može may postaviti be placed marker into the kako tumour bi se pomoglo to help surgeons hirurzima remove da kasnije the odstrane whole ceo tumour tumor. at a later date. 15

16 Rak Breast dojke cancer Kako How will će biti my određena treatment moja be determined? terapija? Kada Once Vam diagnosed postavi with dijagnoza breast cancer, za Vas će you se will pobrinuti be looked tim after stručnjaka by a team za rak of dojke breast cancer specialists Vaše Your lečenje treatment zavisiće will depend od toga on koliko a number je uznapredovao of factors, Vaš rak, including vrstu raka how (pogledajte far advanced odeljak your cancer u nastavku) is, the i procenu type rizika. of cancer (see section below) and risk assessment. Lečenje Treatment se is najbolje best done vrši in u specijalističkom a specialist centre centru that u kome se cares zbrinjava for a high veliki number broj pacijenata of breast sa cancer rakom patients. dojke. Tim koji Vas leči obično se sastoji od hirurga, radiologa, The team treating you will typically include a surgeon, medikalnogonkologa, radioterapeita i patologa. Trebalo radiation oncologist, medical oncologist, radiologist bi da Vam bude na raspolaganju i medicinska sestra and pathologist. A nurse specialist should also be specijalizovana za tu oblast koja će Vas voditi kroz available to guide you through each stage of diagnosis svaki stadijum dijagnoze i lečenja. and treatment. Određivanje Staging stadijuma It is important for your doctor to know the stage Važno je da Vaš lekar zna stadijum bolesti kako bi of the cancer so that he/she can determine the mogao da odredi najbolji terapijski pristup best treatment approach 16 Određivanje stadijuma raka koristi se da opiše njegovu veličinu i položaj, kao i da li se proširio sa mesta na kome se Staging pojavio. of cancer is used to describe its size and position and whether it has spread from where it started. Kliničko Clinical određivanje staging involves stadijuma a physical obuhvata examination, i fizikalni pregled, blood tests analize and krvi imaging. i snimanja. In addition Osim to početne your initial mamografije, mogu mammography, biti potrebna further i dodatna scans snimanja, may also uključujući be required, i kompjuterizovanu including a computed tomografiju tomography (CT) Vašeg (CT) scan grudnog of your koša, chest, ultrazvuk, an ultrasound, CT ili CT MR or snimak MRI scan Vašeg of stomaka your abdomen i snimak and kostiju. a bone Za scan. pregled Alternatively, kompletnog a positron organizma emission može biti iskorišćena tomography i pozitronska (PET) scan may emisiona be used tomografija assess the (PET). whole body. Kompjuterizovana CT scan: This is a type tomografija: of x-ray technique To je vrsta that rendgen lets doctors tehnike see koja your omogućava internal organs lekaru in da cross-section. vidi unutrašnje organe MRI scan: u preseku. MRI uses magnetic fields and radio waves to produce detailed images of the inside of your body. Magnetna Bone scan: This rezonanca: test involves Magnetna a small rezonanca amount of radioactive koristi magnetna substance polja injected i radio-talase into a za vein pravljenje and allows slika unutrašnjosti doctors to see organizma. abnormal areas of bone across your whole body, as abnormal bone absorbs more Snimak radioactivity kostiju: than Ovaj healthy test se bone. izvodi tako što se mala količina radioaktivne materije ubrizga u venu i tako lekari mogu PET scan: da vide PET postojeće uses a radioactive promene u substance svim kostima injected tela, jer into kost a vein koja and ima can promene help identify upija više areas radioaktivnosti of cancer that od zdrave an MRI kosti. or CT scan may miss. Most PET scans are now performed along with a CT scan. Pozitronska emisiona tomografija: PET koristi radioaktivnu materiju koja se ubrizgava u venu i pomaže u otkrivanju delova raka koje MR ili CT snimci mogu da propuste. Većina PET snimanja se sada vrši zajedno sa CT snimanjem.

17 ESMO Vodič Patients za pacijente Guide Hirurško određivanje stadijuma bolesti zasniva se na analizi tkiva uklonjenog tokom operacije. Surgical staging is based on examination of the tissue removed during surgery. Određivanje stadijuma raka u cilju određivanja veličine i proširenosti tumora opisuje se primenom niza slova i Cancer staging to determine the size and spread of the tumour is described using a sequence of letters and brojeva. Za rak dojke postoji pet stadijuma obeleženih rimskim brojevima od 0 do IV. Uopšteno govoreći, što je niži numbers. For breast cancer, there are five stages designated with Roman numerals 0 to IV. Generally, the lower stadijum, to je bolja prognoza. TNM klasifikacija određivanja stadijuma uzima u obzir sledeće: the stage, the better the prognosis. The TNM staging system considers: Koliki je rak, ili veličinu tumora (T) How big the cancer is, or tumour size (T) Da Whether li se rak the proširio cancer u has limfne spread čvorove to lymph (noduse) nodes (N) (N) Da Whether li se proširio it has spread na udaljena to distant mesta, sites, ili metastaze or metastases (M) (M) Biopsija Lymph node limfnih biopsy čvorova Biopsija Lymph node limfnih biopsy čvorova is an predstavlja important part važan of deo breast određivanja cancer staging. stadijuma Fine raka needle dojke. aspiration Uzorkovanje of suspicious sumnjivih lymph limfnih čvorova nodes is tankom performed iglom to vrši confirm se kako or exclude bi se potvrdilo the presence ili isključilo of metastases prisustvo metastaza in the lymph u limfnim nodes before čvorovima start pre početka of therapy. terapije. To evaluate Kako bi lymph se procenila node involvement, zahvaćenost limfnog a process čvora called obično sentinel se lymph vrši proces node nazvan biopsy biopsija is usually limfnog čvora performed sentinela (Cardoso (Cardoso et al et al. [in 2018 press]), [u štampi]), in which tokom the sentinel koga se lymph limfni node čvor (the sentinel first lymph (prvi limfni node čvor to which na koji cancer će se ćelije cells are raka most iz tumora likely to najverovatnije spread from proširiti) a tumour) određuje, is identified, uklanja removed i proverava and checked na prisustvo for the ćelija presence raka. of cancer cells. Sistem The stage grupisanja grouping stadijuma system for za breast rak dojke cancer opisan described je u tabeli in u nastavku the table (Cardoso below (Cardoso et al et al. [u 2018 štampi]). [in press]). Tabela This Vam may može izgledati seem complicated komplikovano, but your ali Vaš doctor lekar will će moći be able da to Vam explain objasni which koji part njen of deo this se table odnosi corresponds na Vaš tip karcinoma. to your cancer. 17