Just as important as making a proper diagnosis of cancer when it exists is not making the diagnosis prematurely without definitive proof. Although this point may seem obvious, the reality is that medicine can be complex. Pathology results are sometimes not definitive, biopsies may need to be repeated, and a sample may need to be evaluated by several expert pathologists before a correct diagnosis is rendered. A guiding principle in the practice of oncology is that, with rare exception, absolute proof of a cancer diagnosis must exist before any treatment is initiated. Sometimes the biopsy needs to be sent to outside consultants who require additional time, so a definitive diagnosis may not be obtained for a week or more. Most patients understandably become anxious and upset when they are told, We still don't know exactly what type of cancer you have, but we are performing more sophisticated testing, which will take more time." Yet because of how important it is to be correct, and the fact that the entire treatment plan follows from the diagnosis, this time spent waiting is worth the wait.
Janet was referred to me after having been told that she had multiple myeloma, a bone marrow cancer. She walked into the examination room quietly in visible pain owing to a recent fracture of a spine bone. Her face was downcast but showed a mixture of physical discomfort and fear. Janet was helped onto the examination table by her husband, Dave, who stood erect and imposing, right beside her. She let him do most of the talking. He was tough looking. With a fierce gaze, he stared unblinkingly at me as he spoke in short, strong phrases. This is my baby, she saved my life when I was down," he said, as he got choked up and brought her snugly to his chest with his arm. Now it's your job to save her life. I know you won't fail us. I won't let it happen." A shiver ran down my spine. I told them I would do my best to make her well, because I fight for all my patients as if they were my family. I quickly focused on her situation.
Janet was thought to have multiple myeloma after an abnormal protein was found in her blood and a biopsy of the fractured vertebra showed some of the cells that are typically found in that bone marrow cancer. But I was not convinced by the whole picture. I ordered an additional analysis of the cells, and it showed that they were not cancerous but rather were part of the body's normal immune reaction to injury. Further investigation for myeloma cells in other parts of her body failed to turn up any sign of the disease. In the end, Janet was spared a cancer diagnosis and remains without evidence of myeloma five years later. Her pain was adequately addressed, her condition improved greatly, and she and her husband were grateful. I was extremely happy for them and breathed a sigh of relief for myself. Because of the enormous weight placed on pathology results, I highly recommend that every cancer patient make certain that his or her oncologist is satisfied with the findings and diagnosis of the pathologist. If there is any uncertainty, have the specimen reviewed by a pathology consultant at another hospital.
Once a cancer diagnosis is made, the next step is to determine whether the cancer has spread from its site of origin and, if it has, to locate all the places in the body where it is growing. The process of accomplishing this is called the staging workup," because after it is completed, the cancer will be assigned a stage." The stage is extremely important to know because treatment plans are designed based on the extent and location of the cancer. The stage of a cancer directly correlates with the likelihood of cure: in general, the higher the stage number, the more widespread the cancer and less favorable the outcome.
It is important to realize, however, that the relation between stage and prognosis is not absolute. Some stage I cancers can behave aggressively and return to take the patient's life, whereas some stage IV cancers can be eradicated. Several factors in addition to stage affect the survivability of a cancer.
The staging workup typically involves the following: (1) imaging studies, such as X-rays, CT and MRI scans, bone scans, and sometimes PET scans, all of which locate cancer throughout the body (other kinds of testing may also be required, as dictated by the type and location of the cancer); (2) analysis of surgical results, especially if a cancer and its nearby lymph nodes are removed in this case, the pathologist will be able to assign a pathologic stage"; and (3) blood tests to measure tumor markers and how well the bone marrow, kidneys, and liver are functioning.
The staging system for the most common cancers (such as breast, lung, and colon cancers) recognizes that there is a direct relation between the extent of cancers and their ultimate curability. The extent of a cancer is described by the TNM staging system, in which T stands for the size or extent of the primary Tumor, N stands for the number and location of lymph Nodes that contain cancer, and M stands for the presence or absence of distant Metastases.
Each cancer is staged according to its own TNM classification system. Once a cancer receives T, N, and M assignments, the three elements are combined to define the stage, which commonly has four categories: I, II, III, or IV. For example:
Your oncologist will explain how your cancer's TNM stage was determined. It is important to understand that although cancer tends to spread first to nearby lymph nodes and then to more distant sites in the body, it does not always follow such an orderly or obvious path. A person may be diagnosed with an early-stage cancer, not involving any lymph nodes, and still develop stage IV disease years later. The explanation for this is that cancer cells either bypassed the lymph nodes and spread through the bloodstream or did pass through the lymph nodes but left no traces behind. Researchers are developing methods based on the genetic profile of a cancer that will enable oncologists to predict more accurately which early cancers have the potential to return and which can be cured by surgical removal alone.
In general, the lower the stage, the better the chances are that a cancer can be cured. Yet the fact that cancer relapses affect some individuals with low stages of cancer forms the basis for administering cancer treatments even after surgery has removed all visible evidence of the disease. The TNM staging system does not apply to cancers of the brain or to the blood and lymph cancers leukemia, lymphoma, and multiple myeloma. These cancers have their own unique staging systems because they behave very differently from the more common cancers. For example, in leukemia, the cancer cells circulate in the bloodstream throughout the body; they would all be metastatic under the TNM system. In fact, most leukemias are not staged but are instead classified" by the specific genetic defects they harbor. Multiple myeloma, Hodgkin lymphoma, and non-Hodgkin's lymphoma do have established staging systems.
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