Breast Anatomy• Four quadrants• Parenchyma – Alveoli Lobules Lobes – Three tissue types • Glandular epithelium • Fibrous stroma and supporting structures • Fat – Cooper ligaments • Fibrous continuations of the superficial fascia, which span the parenchyma of the breast to the deep fascial layers
Breast Anatomy• Nerves – Long thoracic nerve – Thoracodorsal nerve – Medial pectoral nerve – Lateral pectoral nerve
Breast Anatomy• Lymphatics – Axillary chain • Level 1 – lateral to pectoralis minor muscle • Level 2 – along and under pectoralis minor • Level 3 - medial to pectoralis minor – Rotter’s nodes • Between pectorial minor and major muscles – Internal mammary chain (relatively minimal drainage) • Parasternal • medial
Regional Lymph Nodes for Breast• Infraclavicular (subclavicular) lymph nodes – In the deltopectoral groove• Supraclavicular lymph nodes – Above the collarbone
Classification Based On Clinical Features Mastalgia Cyclic Non Cyclic Tumors and Masses Nodularity or glandular Cysts Galactoceles Fibroadenoma Sclerosing Adenosis Lipoma Harmatoma Diabetic Mastopathy Cystosarcoma Phylloides
Classification Based On Clinical Features Nipple discharge Galactorrhea Abnormal nipple discharge Breast infections and Inflammation Intrinsic mastitis Postpartum engorgement Lactation mastitis Lactation breast abscess Chronic recurrent subareolar abscess Acute mastitis associated with macrocystic breasts Extrinsic infections Mondor’s Disease Hidradenitis suppurativa
Benign Breast Disease• Infectious and inflammatory• Benign lesions• Nipple Discharge• Mastalgia
Infectious and Inflammatory Breast Disease• Cellulitis, mastitis – Usually associated with lactation – Treat with 10-14 day course antibiotics to cover Staphylococcus and Streptococcus• Abscess – Treated by surgical drainage• Chronic subareolar abscess – Occurs at base of lactiferous duct, and squamous metaplasia of duct may occur. – Sinus tract to areola develops – Treatment requires complete excision of sinus tract – Recurrence is common• Mondor’s disease – Phlebitis of the thoracoepigastric vein – Palpable, visible, tender cord along upper quadrants – Ultrasound may be helpful in confirming this diagnosis. – Treatment self-limited, can use anti-inflammatories if necessary
Benign Lesions of the Breast• Fibrocystic breasts – Broad spectrum of clinical and histologic findings – Loose association of cyst formation, breast nodularity, stromal proliferation, and epithelial hyperplasia. – Appears to represent an exaggerated response of breast stroma and epithelium to hormones and growth factors. – Dense, firm breast tissue with palpable lumps and frequently gross cysts, commonly painful and tender to touch. – No consistent association between fibrocystic complex and breast cancer.
Benign Lesions of the Breast• Cysts – Fluid-filled, epithelium-lined cavities – Influenced by ovarian hormones • Explains sudden appearance during the menstrual cycle, their rapid growth, and their spontaneous regression with completion of the menses. – Common after age 35, and rare before 25. Incidence declines after menopause. – Three colors by needle aspiration • Simple cyst, clear or green fluid and is benign. • Milk-filled cyst, called galactocele and is benign. • Bloody cyst is a cause of concern for malignancy. – Tx depends on whether the cyst completely resolves after aspiration • Complete resolution, will follow up to ensure it does not recur. • Incomplete resolution, Treat as breast mass and excise.Fluid-filled, epithelium-lined
Benign Lesions of the Breast• Fibroadenoma – Well-defined, mobile benign tumor of breast – Composed of both stromal and epithelial elements in the breast – Common in younger women, and is most common tumor in women younger than age 30 years – Can be diagnosed by FNA and followed if < 2-3 cm and age < 35 – Otherwise Dx by excision. At operation are well-encapsulated and detach easily.• Phyllodes tumors (cystosarcoma phyllodes) – Giant fibroadenomas – Rarely malignant – Treat with wide local excision
Benign Lesions of the Breast• Sclerosing adenosis – Proliferation of acini in the lobules, which may appear to have invaded the surrounding breast stroma. – Can simulate carcinoma both grossly and histologically.• Epithelial and atypical hyperplasia – Involves ducts or lobules – If greater than moderate hyperplasia then indicates higher risk of breast cancer• Papilloma – Polyps of epithelium-lined breast ducts – Located under the areola in most cases – When under the nipple and areolar complex it often present with a bloody nipple discharge. – Treatment is total excision through a circumareolar incision. – Need to rule out invasive papillary carcinoma.
Benign Lesions of the Breast• Mammary duct ectasia – Generally found in older women. – Dilatation of the subareolar ducts can occur. – A palpable retroareolar mass, nipple discharge, or retraction can be present. – Tx involves excision of area.• Fat necrosis – Associated with trauma or radiation therapy to breast. – Can simulate cancer with mass or skin retraction. – Bx is diagnostic and generally with lipid-laden macrophages, scar tissue, and chronic inflammatory cells.
Benign Breast Disease• Nipple discharge – Pathologic nipple discharge is persistent and spontaneous and is not associated with nursing. • Requires further evaluation • Galactorrhea – Bilateral, milky discharge occurs – Obtain prolactin levels, if highly elevated, suspect pituitary adenoma as one of causes. • Bloody nipple discharge – Most common cause is intraductal papilloma – Cancer present 10% of time. – Cytologic exam on discharge – Mammogram to rule out associated mass – If drainage from isolated duct, then it should be excised.
Benign Breast Disease• Mastalgia – Cyclic pain • Correlates with menstrual cycle. • Can attempt to treat with danazol or bromocriptine – Non-cyclic pain • Drugs can be effective placebo • NSAIDS may help • Avoid caffeine and wear a supportive bra – Cancer must be excluded through examination, mammogram, and ultrasound if the pain is localized.
Evaluation & Management of Breast Pain Mastalgia should be treated when: It is severe enough to interfere with a woman’s life style It occurs more than a few days every month. History and Physical Diagnostic work up MammogramMicheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Management of Breast PainTreatment Goals Alleviate pain Reduce or relieve irregularity Rule out cancer of the breast
Management of Breast Pain Diet and Lifestyle Modification Elimination of Methylxanthines, Caffeine and Chocolates Reassurance Supportive Bra Low fat and high complex carbohydrate Vitamin E supplementation Evening Primrose oilMicheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Management of Breast Pain Pharmacological Treatment NSAIDs OCPs Danazol 100- 400mg per day 75% of women with non cyclic pain will be symptom free SE: Weight gain , menstrual irregularity , acne , hirsutism Tamoxifen 10mg Bromocriptine – prolactin antagonist Surgery has no role in management of breast painMicheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Evaluation & Management of Breast PainAAFP journal , April 15, 2000. Volume 61/ No. 8
Breast Masses Normal glandular tissue of the breast is nodular This is a general pattern or consistency of the breast which include persistent lumpiness or nodularity which is generally not abnormal when it is related to the menstrual cycle. Dominant masses are characterized by persistence throughout the menstrual cycle
Breast Masses: Cysts Cystic Breast Mass Common cause of dominant breast mass May occur at any age, but uncommon in post menopausal women Fluctuates with menstrual cycle Well demarcated from the surrounding tissue Characteristically firm and mobile May be tender Difficult to differentiate from solid massMicheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Masses: Cysts Fibrocystic Breast Disease Most common of all benign breast disease Most common between ages 20- 50 50% of women with Fibrocystic changes have clinical symptoms 53% have histologic changes Believed to be associated the Imbalance of progesterone and estrogen. May present with bilateral cyclic pain, breast swelling, palpable mass and heaviness
Fibrocystic Breast Disease Physical Examination Tenderness Increased engorgement and more dense breast Increased lumpiness / glandular Occasional spontaneous nipple dischargeMicheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Cysts: Diagnostics Mammogram Fine Needle Aspiration Cystic outline Outpatient procedure No calcification Non bloody fluid No increased density Cyst disappears Ultra Sonogram If bloody fluid, surgical Cyst biopsy of cyst is required Reexamination 4-6 weeks after aspiration
Management of Breast CystsAAFP journal , April 15, 2000. Volume 61/ No. 8
Breast Mass: Fibroadenomas Simple: Second most common benign breast lesion Benign solid tumors containing glandular as well as fibrous tissue . Usually present as well defined, mobile mass Commonly found in women between the ages of 15 and 35 years Cause is unknown, thought to be due to hormonal influence May increase in size during pregnancy or with estrogen therapy Giant: Fibroadenomas over 10cm in size Excision is recommended Juvenile Variant of fibroadenomas Found in young women between the ages of 10 -18. Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral masses Excision is recommended
Breast Mass: Fibroadenomas (Cont’d) Complex Complex fibroadenomas contain other proliferative changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification. Associated with slightly increased risk of cancerDupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Mass Phylloides Tumors: Rapidly growing One in four malignant One in Ten Metastasize Create bulky tumors that distort the breast May ulcerate through the skin due to pressure necrosis Treatment consists of wide excision unless metastasis has occurred Fat Necrosis: Rare Secondary to trauma- often not remembered Tender, ill defined mass Occasionally skin retraction Treat with excisional biopsy
Breast Mass Galactocele Milk filled cyst from over distension of a lactiferous duct. Presents as a firm non tender mass in the breast, Commonly in upper quadrants beyond areola. Diagnostic aspiration is often curative. Duct ectasia: Generally found in older women. Dilatation of the subareolar ducts can occur. A palpable retroareolar mass, nipple discharge, or retraction can be present. Tx involves excision of area
Nipple Discharge Majority of causes are benign Most common cause is lactational Overstimulation also common Prolactin secreting tumors Hypothyroidism Drugs Intraductal and other carcinomas Unilateral, spontaneous, bloody discharge is suspicious
Nipple Discharge Intraductal Papilloma Benign growth within ductal system Presents as bloody nipple discharge Excision is the only way to differentiate from carcinoma Galactorrhea Bilateral milky discharge Obtain prolactin level, TSH level
Breast Inflammation & Infections Mastitis Most common in lactating female Dry, cracked fissured areola/nipple complex provides portal for infection Usually caused by Staph/Strep organisms Rule out malignancy Treat with heat, continued breast feeding, Antibiotics for 10-14 days to cover staph and strept infections
Breast Inflammation & Infections Abscess May present with breast swelling, tenderness and fever On PE, breast is tender , warm and fluctuant, may also have purulent discharge Treated by surgical drainage
Breast Inflammation & Infections Mondor’s Disease Phlebitis of the thoracoepigastric and lateral thoracic vein Palpable, visible, skin retraction over tender extending to chest wall Spontaneous or related to trauma Ultrasound may be helpful in confirming this diagnosis. Treatment self-limited, can use NSAIDs Mammogram if over 35yo to r/o malignancy
Breast Inflammation & Infections Chronic Subareolar Abscess Occurs at base of lactiferous duct, and squamous metaplasia of duct may occur. Sinus tract to areola develops Treatment requires complete excision of sinus tract Recurrence is common
Fibroadenoma Discussion Features – Usually younger women – Usually solitary mass, occasionally multiple – May increase with pregnancy or involute post- menopause Pathology – Benign tumor – Circumscribed rubbery mass – Overgrown fibrous stroma compressing epithelium – May have some increased risk of breast cancer long term especially if associated with proliferative breast pathology*
• A woman has a 1 in 8 chance of developing breast cancer at some point in her life.• Risk factors – Increased age, family history, History of breast, ovary, or endometrial cancer, >30 age at first pregnancy, high socioeconomic status, nulliparity, early menarche, and late menopause• Symptoms – Lumps • Presenting symptom in 85% of patients with carcinoma – Pain • Must completely evaluate to rule out carcinoma – Metastatic disease • Axillary nodes • Distant organ symptoms, such as neurological – Asymptomatic • Why we advise yearly SBE and yearly mammogram after age 50
Malignant Diseases of the Breast• Non-invasive breast cancers – 10% of all types of breast cancer – Good prognosis – Ductal carcinoma in situ, lubular carcinoma in situ, and paget’s disease• Invasive breast cancers – Favorable histologic types (85% 5-year survival rate) • Tubular carcinoma (grade 1 intraductal), colloid or mucinous carcinoma, and papillary carcinoma – Less favorable types • Medullary cancer, invasive lobular cancer, and invasive ductal cancer – Least favorable type • Inflammatory breast cancer
Ductal Carcinoma in Situ• Seen as microcalcifications on mammogram• Confined to ductal cells.• No invasion of the underlying basement membrane.• Chance of recurrence 25-50% in 5 years, of these 50% will be invasive• Tx – Mastectomy an option if there is a substantial risk of local/regional recurrence – Wide local excision and radiation reduce local recurrence to 2% – Wide excision alone suitable if <25mm, favorable histology, and the margins are clear – Node dissection not necessary (nodal disease < 1%)
Lobular Carcinoma in Situ• Not detectable on mammography – Most commonly found incidentally• Risk of invasive breast cancer in 20 years is 15- 20% bilaterally• Tx – Careful follow-up – Bilateral masectomy may be considered if other risk factors are present such as family history or prior breast cancer, and also dependent on patient preference.
Invasive Breast Cancers• Favorable histologic types (85% 5-year survival rate) • Tubular carcinoma (grade 1 intraductal), colloid or mucinous carcinoma, and papillary carcinoma• Less favorable types • Medullary , invasive lobular, and invasive ductal carcinoma• Least favorable type • Inflammatory breast carcinoma• Staging, prognosis, and treatment
Favorable histologic types• Tubular carcinoma – 2% of all invasive breast cancers – Generally diagnosed by mammography – Distinctive under microscope – Long-term survival aproaches 100%• Mucinous (colloid) carcinoma – 3% of all invasive breast cancers – Generally confined to elderly population – Bulky, mucinous tumor with characteristic microscopic features – 5 and 10 year survival rates are 73 and 59 percent, respectively• Papillary carcinoma – <2% of all invasive breast cancers – Generally presents in seventh decade, and is a slowly progressive disease – 5 and 10 year survival rates are 83 and 56 percent, respectively
Less Favorable Histologic Types• Medullary carcinoma – 4% of all invasive breast cancers – Soft, hemorrhagic bulky presentation – Diagnosed microscopically (lymphocytic infiltration) – Metastases to axillary nodes in 44% – 5 and 10 year survival rates are 63 and 50 percent respectively• Invasive ductal carcinoma – Most common and occurs in 78% of all invasive breast cancers. – Metastases to axillary nodes in 60% – 5 and 10 year survival rates are 54 and 38 percent respectively• Invasive lobular carcinoma – 9% of all invasive breast cancers – Metastases to axillary nodes in 60% – 5 and 10 year survival rates are 50 and 32 percent respectively – Higher incidence of bilaterality
Inflammatory carcinoma• 1.5-3% of breast cancers• Characteristic clinical features of erythema, peau d’orange, and skin ridging with or without a palpable mass.• Commonly mistaken for cellulitis. – Will generally fail antibiotics before being diagnosed• Disease progresses rapidly, and more than 75% of patients present with palpable axillary nodes.• Distant metastatic disease also at much higher frequency than the more common breast cancers.• 30% 5 year survival rate• Requires chemotherapy treatment immediately
Diagnosis• Fine-needle aspiration – Sensitivity is 80-98%, specificity 100% – False negatives are 2-10%• Core-needle biopsy – More tissue, however still possibility of false “negative” and could represent sampling error• Incisional biopsy – For large (>4 cm) lesions for whom pre-op chemotherapy or radiation will be desirable.• Excisional biopsy – Removal of entire lesion and a margin of normal breast parenchyma
Thermograph• Thermograph is one of the newest ways to detect breast cancer.• Thermograph is a thermal image of the breast tissue.• It can also detect cancer before the traditional mammogram can.• www.breastthermography.com• Picture from breastthermography.com
Staging and Prognosis• Primary Tumor – T1 = Tumor < 2 cm. in greatest dimension – T2 = Tumor > 2 cm. but < 5 cm. – T3 = Tumor > 5 cm. in greatest dimension – T4 = Tumor of any size with direct extension to chest wall or skin• Regional Lymph Nodes – N0 = No palpable axillary nodes – N1 = Metastases to movable axillary nodes – N2 = Metastases to fixed, matted axillary nodes• Distant Metastases – M0 = No distant metastases – M1 = Distant metastases including ipsilateral supraclavicular nodes• Clinical Staging and prognosis – Clinical Stage I T1 N0 M0 Stage Prognosis (5 year surv. Rate) – Clinical Stage IIA T1 N1 M0 I 93% – T2 N0 M0 II 72% – Clinical Stage IIB T2 N1 M0 III 41% – T3 N0 M0 IV 18% – Clinical Stage IIIA T1 N2 M0 – T2 N2 M0 – T3 N1 M0 – T3 N2 M0 – Clinical Stage IIIB T4 any N M0 – Clinical Stage IV any T any N M1
Prognostic Features• Tumor size important prognostic factor• Poor prognostic features of tumor: – Presence of edema or ulceration of skin, mass fixed to chest wall or skin, satellite skin nodules, peau d’orange (dermal lymphatic invasion), skin retraction and dimpling, and involvement of medial portion of inner lower quadrant involved.• Axillary node status: – Best source of predicting survival or outcome – N0 has 10 year survival rate of 60% – N1 has 10 year survival rate of 50% – N2 has 10 year survival rate of 20% – If 10 or more nodes are diseased (N3) 10 yr surv. Rate is 14% – Poor prognostic feature of nodes: • Capsular invasion, extranodal spread, and edema of arm• Distant metastases is very poor prognostic indicator• Postive estrogen and progesterone receptor indicates likely response to hormonal treatment and is a positive prognostic indicator
Treatment• Modalities (palliative vs. curative) – Surgery • Local treatment – Radiation • Local treatment – Chemotherapy and hormonal therapy • Systemic treatment
Surgery– Breast conservation therapy • Stage I, stage II, and sometime stage III carcinomas • Lumpectomy, axillary lymphadenectomy, and postoperative radiation therapy • Contraindications: tumors > 5 cm , gross multifocal disease, and diffuse malignant microcalcifications • Local recurrence more than mastectomy so follow up important– Modified radical mastectomy (most common mastectomy procedure for invasive breast cancer) • Entire breast and axillary contents are removed • Pectoralis muscles remains– Halsted radical mastectomy • Removes breast, axillary contents, and pectoralis major muscle • Cosmetically deforming • Only indicated when pectoralis muscle involved– Simple mastectomy • All breast tissue is removed, axillary contents not removed • Treatment for non-invasive breast cancer
Radiation• Utilized for primary and metastatic disease• Useful in breast conservation therapy to reduce rate of recurrence. – Radiate entire breast
Chemotherapy and Hormonal Therapy• Chemotherapy – Eradicates risk of occult distant disease in stage I and stage II patients. – All patients with axillary node involvement are candidates along with patients with negative axillary node involvement who are high risk by other prognostic indicators. – Example treatment is 6 months of cyclophosphamide, methotrexate or adriamycin, and flourouracil along with paclitaxel. • Improvement in disease free interval and overall survival• Hormonal therapy – Tamoxifen • Generally taken for five years in patientss with estrogen receptor positive tumors. – As effective as chemotherapy in post-menopausal patients with estrogen receptor positive tumors
Classification Lesions with Increased Risk of Ca Ductal hyperplasia Sclerosing adenosis Complex fibroadenomas Atypical hyperplasia Radial scarsMicheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Classification Lesions with no Increased risk of Ca Fibrocystic disease Duct ectasia Solitary papillomas Simple fibroadenomas Mastitis or breast abscess Galactocele Fat necrosis Lipoma
Alternative medicine• There are also several alternative medicines that can help to reduce or eliminate breast cancer.• Vitamin A, Betacarotine, Vitamin C, and Vitamin E all increase the effect of chemotherapy.• CO-Q10 reduces the toxicity of chemotherapy• Vitamin D, and Cholecalciferol helps inhibits growth in cancer cells• Melitonin (which is a natural chemical produced in our brain) blocks the estrogen receptors to the cancer
Alternative medicine• Also Astragalus acts as an anti-viral and enhances the natural killer cells• Cur cumin turmeric (is an anti tumor) increases you leukocyte production• And Caud’ Arco is a mild herb that acts as an anti tumorTherapeutic massage, acupuncture, and stress relieving techniques are also used. Treat the whole person not just the illness
Bone marrow transplant• Getting a bone marrow transplant is one of the newest options for cancer.• It is used when you receive high doses of radiation and chemotherapy. Because chemotherapy kills all the cells both good, and bad it replaces what was destroyed by the treatments.• Bone marrow is donated from another person and then frozen and placed in the cancer patients body by injection.• A word of caution though this is still in the preliminary stages of trials & testing for breast cancer.
Nutrition• Perhaps one of the best ways to help prevent cancer is an easy one but often overlooked.• Diets high in meat, fast foods, refined carbohydrates, simple sugars, low in fruit and veggies are at high risk of developing cancer.• Diets need to be well balanced in that you need to eat your 5 servings of fruits and veggies a day. Don’t forget the whole grain foods as well.• Picture from usda.gov
Nutrition• Alcohol is associated with increasing the chances of many types of cancer, including breast cancer.• “An average alcohol intake of three drinks per day is associated with doubling the risk of breast cancer”• (chapter 16 core concepts in health, Insel)• One should also avoid smoking because it increases the risk also.• Fiber is also an interregnal part of our daily diets. Many foods that contain fiber also contain many other vitamins that are considered “potential cancer fighting agents”.• Fruits and veggies also contain anti carcinogens, carotenoids, antioxidants, and free radicals that help protect our DNA.
Exercise• Another aspect is to maintain a healthy body weight.• That means to get off the couch an do something, walk the dog, ride a bike or just exercise in you own home.• If you stay away from fatty foods, (i.e.; fast foods) and eat a well balanced diet. Then you will greatly reduce your chances of getting cancer.• Don’t forget to take care of your self!!
Age as a Risk Factor RISKBy age 30 1 out of 2,000By age 40 1 out of 233By age 50 1 out of 53By age 60 1 out of 22By age 70 1 out of 13By age 80 1 out of 9Lifetime risk 1 out of 8NCI SEER Program, 1995-1997
Risk FactorsControllable Uncontrollable• Alcohol drinking • Getting older• Being overweight • First degree• Never having relative with breast children cancer• 1st child >30yrs of • A previous breast age biopsy showing• Hormone atypical changes Replacement• Birth control pills
Risk Factors• Controllable • Uncontrollable• Being exposed to • Being young (<12) at the large amounts of time of menses radiation • Starting menopause after age 55 • Having an inherited mutation in the breast cancer genes (BRCA 1 or 2) ACS Breast Cancer Facts 2001-02
Breast Cancer Screening Methods For Healthy Women1. Breast Self Exam — Status – Guiding principal “Know your breasts — they are not land mines”2. Clinical Breast Exam – Age 20-39: every 3 years – Age after 40: every year3. Mammography – Age after 40: every year
Paget’s Disease• Uncommon• Usually involves the nipple• Histologically, vacuolated cells are seen in the epidermis of the nipple and result in an eczematous dermatitis of the nipple.• It is generally associated with an underlying intraductal or invasive carcinoma. – Mammography should be performed• About 30% of patients have axillary node metastasis at diagnosis.• Mastectomy is the standard of treatment – 80% have a 10 year survival rate if there is no mass present and no axillary nodes are involved.
The Male Breast• Gynecomastia – Prepubertal gynecomastia • Rare, adrenal carcinoma and testicular tumor can cause this. – Pubertal gynecomastia • Occurs in 60-70% of pubertal boys. – Senescent gynecomastia • 40% of aging men have this to some degree. • Drugs, such as steroids, digitalis, hormones, spironolactone, and antidepressants can cause this.• Male breast carcinoma – 0.7% of all breast cancers – <1% of male cancers – Average age of diagnosis is 63.6 years old – Painless unilateral mass that is usually subareolar with skin fixation, chest wall fixation,, and ulceration. – Mostly ductal carcinoma – Males generally present at later stage than woman • Overall survival worse in men, however when compared stage for stage the survival rates are similar.