Diagnosis and Staging

Cancer can cause many different symptoms. Most often these symptoms are not caused by cancer, but by benign tumors or other problems. If you have symptoms that last for a couple of weeks, your doctor will do a physical exam and order tests or other procedures to find out what is causing your symptoms.

If you do find out you have cancer, your doctor will order another set of tests or procedures to figure out its stage. Stage refers to the extent of your cancer and is based on factors such as how large the tumor is and if it has spread. Once your doctor knows the stage of your cancer, he will be able to suggest treatment and discuss your prognosis with you. Understanding your cancer and knowing what to expect can help you and your loved ones feel more in control and cope with your diagnosis.

• Symptoms
• Understanding Cancer Diagnosis
• What is Cancer Staging?
• Understanding Cancer Prognosis
• Questions to Ask about Your Cancer Diagnosis

Symptoms

Cancer can cause many different symptoms. Only a doctor can tell if your symptoms are caused by cancer or some other problem.

Cancer can cause many different symptoms. These are some of them:

• Skin changes, such as:
  • A new mole or a change in an existing mole
  • A sore that does not heal
• Breast changes, such as:
  • Change in size or shape of the breast or nipple
  • Change in texture of breast skin
• A thickening or lump on or under the skin
• Hoarseness or cough that does not go away
• Changes in bowel habits
• Difficult or painful urination
• Problems with eating, such as:
  • Discomfort after eating
  • A hard time swallowing
  • Changes in appetite
• Weight gain or loss with no known reason
• Abdominal pain
• Unexplained night sweats
• Unusual bleeding or discharge, including:
  • Blood in the urine
  • Vaginal bleeding
  • Blood in the stool
• Feeling weak or very tired

Most often, these symptoms are not due to cancer. They may also be caused by benign tumors or other problems. If you have symptoms that last for a couple of weeks, it is important to see a doctor so that problems can be diagnosed and treated as early as possible.

Usually, early cancer does not cause pain. If you have symptoms, do not wait to feel pain before seeing a doctor.

Understanding Cancer Diagnosis

Learn about tests and procedures that doctors might order in order to diagnose cancer.

If you have a symptom or your screening test result suggests cancer, the doctor must find out whether it is due to cancer or some other cause. The doctor may ask about your personal and family medical history and do a physical exam. The doctor also may order lab tests, scans, or other tests or procedures.

Lab Tests

High or low levels of certain substances in your body can be a sign of cancer. So, lab tests of the blood, urine, or other body fluids that measure these substances can help doctors make a diagnosis. However, abnormal lab results are not a sure sign of cancer. Lab tests are an important tool, but doctors cannot rely on them alone to diagnose cancer.

Imaging Procedures

Imaging procedures create pictures of areas inside your body that help the doctor see whether a tumor is present. These pictures can be made in several ways:

• CT Scan:
  An x-ray machine linked to a computer takes a series of detailed pictures of your organs. You may receive a dye or other contrast material to highlight areas inside the body. Contrast material helps make these pictures easier to read.
• Nuclear Scan:
  For this scan, you receive an injection of a small amount of radioactive material, which is sometimes called a tracer. It flows through your bloodstream and collects in certain bones or organs. A machine called a scanner detects and measures the radioactivity. The scanner creates pictures of bones or organs on a computer screen or on film. Your body gets rid of the radioactive substance quickly. This type of scan may also be called radionuclide scan.
• Ultrasound:
  An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues inside your body like an echo. A computer uses these echoes to create a picture of areas inside your body. This picture is called a sonogram.
• MRI:
  A strong magnet linked to a computer is used to make detailed pictures of areas in your body. Your doctor can view these pictures on a monitor and print them on film.
• PET Scan:
  For this scan, you receive an injection of a tracer. Then, a machine makes 3-D pictures that show where the tracer collects in the body. These scans show how organs and tissues are working.
• X-Rays:
  X-rays use low doses of radiation to create pictures of the inside of your body.

Biopsy

In most cases, doctors need to do a biopsy to make a diagnosis of cancer. A biopsy is a procedure in which the doctor removes a sample of tissue. A pathologist then looks at the tissue under a microscope to see if it is cancer. The sample may be removed in several ways:

• With a needle: The doctor uses a needle to withdraw tissue or fluid.
• With an endoscope: The doctor looks at areas inside the body using a thin, lighted tube called an endoscope. The scope is inserted through a natural opening, such as the mouth. Then, the doctor uses a special tool to remove tissue or cells through the tube.
• With surgery: Surgery may be excisional or incisional.
  • In an excisional biopsy, the surgeon removes the entire tumor. Often some of the normal tissue around the tumor also is removed.
  • In an incisional biopsy, the surgeon removes just part of the tumor.

What is Cancer Staging?

Staging is the process of determining details about your cancer, such as how large the tumor is and if it has spread. TNM is the most commonly used staging system.

Stage refers to the extent of your cancer, such as how large the tumor is, and if it has spread. Knowing the stage of your cancer helps your doctor:

• Understand how serious your cancer is and your chances of survival
• Plan the best treatment for you
• Identify clinical trials that may be treatment options for you

A cancer is always referred to by the stage it was given at diagnosis, even if it gets worse or spreads. New information about how a cancer has changed over time gets added on to the original stage. So, the stage doesn't change, even though the cancer might.

How Stage Is Determined

To learn the stage of your disease, your doctor may order x-rays, lab tests, and other tests or procedures.

Systems that Describe Stage

There are many staging systems. Some, such as the TNM staging system, are used for many types of cancer. Others are specific to a particular type of cancer. Most staging systems include information about:

• Where the tumor is located in the body
• The cell type (such as, adenocarcinoma or squamous cell carcinoma)
• The size of the tumor
• Whether the cancer has spread to nearby lymph nodes
• Whether the cancer has spread to a different part of the body
• Tumor grade, which refers to how abnormal the cancer cells look and how likely the tumor is to grow and spread

The TNM Staging System

The TNM system is the most widely used cancer staging system. Most hospitals and medical centers use the TNM system as their main method for cancer reporting. You are likely to see your cancer described by this staging system in your pathology report, unless you have a cancer for which a different staging system is used. Examples of cancers with different staging systems include brain and spinal cord tumors and blood cancers.

In the TNM system:

• The T refers to the size and extent of the main tumor. The main tumor is usually called the primary tumor.
• The N refers to the the number of nearby lymph nodes that have cancer.
• The M refers to whether the cancer has metastasized. This means that the cancer has spread from the primary tumor to other parts of the body.

When your cancer is described by the TNM system, there will be numbers after each letter that give more details about the cancer—for example, T1N0MX or T3N1M0. The following explains what the letters and numbers mean:

Primary tumor (T)

• TX: Main tumor cannot be measured.
• T0: Main tumor cannot be found.
• T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues. T's may be further divided to provide more detail, such as T3a and T3b.

Regional lymph nodes (N)

• NX: Cancer in nearby lymph nodes cannot be measured.
• N0: There is no cancer in nearby lymph nodes.
• N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that contain cancer.

Distant metastasis (M)

• MX: Metastasis cannot be measured.
• M0: Cancer has not spread to other parts of the body.
• M1: Cancer has spread to other parts of the body.

Other Ways to Describe Stage

The TNM system helps describe cancer in great detail. But, for many cancers, the TNM combinations are grouped into five less-detailed stages. When talking about your cancer, your doctor or nurse may describe it as one of these stages:

Stage	What it means
Stage 0	Abnormal cells are present but have not spread to nearby tissue. Also called carcinoma in situ, or CIS. CIS is not cancer, but it may become cancer.
Stage I, Stage II, and Stage III	Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues.
Stage IV	The cancer has spread to distant parts of the body.

Another staging system that is used for all types of cancer groups the cancer into one of five main categories. This staging system is more often used by cancer registries than by doctors. But, you may still hear your doctor or nurse describe your cancer in one of the following ways:

• In situ— Abnormal cells are present but have not spread to nearby tissue.
• Localized— is limited to the place where it started, with no sign that it has spread.
• Regional— has spread to nearby lymph nodes, tissues, or organs.
• Distant— has spread to distant parts of the body.
• Unknown— is not enough information to figure out the stage.

To learn more about staging for your type of cancer, see the PDQ® cancer treatment summaries for adult and childhood cancers.

Understanding Cancer Prognosis

Prognosis describes how serious your cancer is and your chances of survival. Learn about survival statistics and how they are used to estimate prognosis.

If you have cancer, you may have questions about how serious your cancer is and your chances of survival. The estimate of how the disease will go for you is called prognosis. It can be hard to understand what prognosis means and also hard to talk about, even for doctors.

ON THIS PAGE

• Many Factors Can Affect Your Prognosis
• Seeking Information About Your Prognosis Is a Personal Decision
• Understanding Statistics About Survival
• If You Decide Not to Have Treatment
• Understanding the Difference Between Cure and Remission

Many Factors Can Affect Your Prognosis

Some of the factors that affect prognosis include:

• The type of cancer and where it is in your body
• The stage of the cancer, which refers to the size of the cancer and if it has spread to other parts of your body
• The cancer’s grade, which refers to how abnormal the cancer cells look under a microscope. Grade provides clues about how quickly the cancer is likely to grow and spread.
• Certain traits of the cancer cells
• Your age and how healthy you were before cancer
• How you respond to treatment

Seeking Information About Your Prognosis Is a Personal Decision

When you have cancer, you and your loved ones face many unknowns. Understanding your cancer and knowing what to expect can help you and your loved ones make decisions. Some of the decisions you may face include:

• Which treatment is best for you
• If you want treatment
• How to best take care of yourself and manage treatment side effects
• How to deal with financial and legal matters

Many people want to know their prognosis. They find it easier to cope when they know more about their cancer. You may ask your doctor about survival statistics or search for this information on your own. Or, you may find statistics confusing and frightening, and think they are too impersonal to be of value to you. It is up to you to decide how much information you want.

If you do decide you want to know more, the doctor who knows the most about your situation is in the best position to discuss your prognosis and explain what the statistics may mean.

Understanding Statistics About Survival

Doctors estimate prognosis by using statistics that researchers have collected over many years about people with the same type of cancer. Several types of statistics may be used to estimate prognosis. The most commonly used statistics include:

• Cancer-Specific Survival
  This is the percentage of patients with a specific type and stage of cancer who have not died from their cancer during a certain period of time after diagnosis. The period of time may be 1 year, 2 years, 5 years, etc., with 5 years being the time period most often used. Cancer-specific survival is also called disease-specific survival. In most cases, cancer-specific survival is based on causes of death listed in medical records.
• Relative Survival
  This statistic is another method used to estimate cancer-specific survival that does not use information about the cause of death. It is the percentage of cancer patients who have survived for a certain period of time after diagnosis compared to people who do not have cancer.
• Overall Survival
  This is the percentage of people with a specific type and stage of cancer who have not died from any cause during a certain period of time after diagnosis.
• Disease-Free Survival
  This statistic is the percentage of patients who have no signs of cancer during a certain period of time after treatment. Other names for this statistic are recurrence-free or progression-free survival.

Because statistics are based on large groups of people, they cannot be used to predict exactly what will happen to you. Everyone is different. Treatments and how people respond to treatment can differ greatly. Also, it takes years to see the benefit of new treatments and ways of finding cancer. So, the statistics your doctor uses to make a prognosis may not be based on treatments being used today.

Still, your doctor may tell you that you have a good prognosis if statistics suggest that your cancer is likely to respond well to treatment. Or, he may tell you that you have a poor prognosis if the cancer is harder to control. Whatever your doctor tells you, keep in mind that a prognosis is an educated guess. Your doctor cannot be certain how it will go for you.

If You Decide Not to Have Treatment

If you decide not to have treatment, the doctor who knows your situation best is in the best position to discuss your prognosis.

Survival statistics most often come from studies that compare treatments with each other, rather than treatment with no treatment. So, it may not be easy for your doctor to give you an accurate prognosis.

Understanding the Difference Between Cure and Remission

Cure means that there are no traces of your cancer after treatment and the cancer will never come back.

Remission means that the signs and symptoms of your cancer are reduced. Remission can be partial or complete. In a complete remission, all signs and symptoms of cancer have disappeared.

If you remain in complete remission for 5 years or more, some doctors may say that you are cured. Still, some cancer cells can remain in your body for many years after treatment. These cells may cause the cancer to come back one day. For cancers that return, most do so within the first 5 years after treatment. But, there is a chance that cancer will come back later. For this reason, doctors cannot say for sure that you are cured. The most they can say is that there are no signs of cancer at this time.

Because of the chance that cancer can come back, your doctor will monitor you for many years and do tests to look for signs of cancer’s return. They will also look for signs of late side effects from the cancer treatments you received.

Questions to Ask Your Doctor about Your Diagnosis

Suggested questions for patients to ask their doctors when they learn they have cancer and want to know what to expect next.

Learning that you have cancer can be a shock and you may feel overwhelmed at first. When you meet with your doctor, you will hear a lot of information. These questions may help you learn more about your cancer and what you can expect next.

• What type of cancer do I have?
• What is the stage of my cancer?
• Has it spread to other areas of my body?
• Will I need more tests before treatment begins? Which ones?
• Will I need a specialist(s) for my cancer treatment?
• Will you help me find a doctor to give me another opinion on the best treatment plan for me?
• How serious is my cancer?
• What are my chances of survival?