Cancer Staging

Cancer doesn’t discriminate. It affects the young, the old and the in-between, and has likely touched every person's life in some way.

As nurses, we may see cancer's presence more than most, along with the impacts it has on the patient and their family. One of the most asked questions by patients with cancer seems to be about their cancer staging and prognosis.

What is Cancer Staging?

When a patient is diagnosed with cancer, they receive a crash course in the terminology used to describe their diagnosis, and more importantly, their prognosis. However, sometimes they have trouble understanding what it all means.

Cancer staging relates to how much cancer is in the individual’s body and where it is located. Staging provides the healthcare team with information to help plan the patient's treatment and understand their long-term outlook.

Determining the Stage

Cancers are staged depending on several factors. Firstly, the primary tumour is assessed for its size, location and whether it has spread to any nearby areas. Then, nearby lymph nodes are checked to see whether the cancer has spread to them. Lastly, other parts of the body are checked. The spread of cancer to parts of the body far away from the primary tumour is known as metastasis (ACS 2020).

Research has found that at least two-thirds of deaths from solid tumours are caused by metastases (Dillekås, Rogers & Straume 2019).

In different kinds of cancer, other factors are also taken into account to determine staging. These may include the cancer cell type, the grade of the cancer cell and certain pathology tests (ACS 2020).

Blood cancers such as leukemia are generally not staged, as they are likely to have already spread around the body by the time they are identified (ACS 2020). Childhood cancers may use their own staging systems (Healthwise 2019).

TNM System

The most common staging system is the American Joint Committee on Cancer’s TNM system, which stands for tumour (T), node (N) and metastasis (M). (ACS 2020). This system is used to describe cancers that are in the form of solid tumours (Cancer.Net 2018).

• T (Tumour): The size and location of the primary tumour and how much it may have grown into tissues nearby.
• N (Node): Whether the cancer has been found in the lymph nodes. If it has, then it also describes how many of the lymph nodes contain cancer.
• M (Metastasis): Whether the cancer has metastasised.

(Cancer.Net 2018)

When cancer is staged using the TNM system, letters and numbers are often used to provide more information regarding the cancer. This may look like T1N0M0 or T2N1MX. Each letter and number relates to the 3 sections of the system:

Tumour

• TX: Main tumour cannot be measured.
• T0: Main tumour cannot be found.
• Tis: The tumour has not yet grown beyond the layer of cells where it started.
• T1, T2, T3, T4: These describe the size and extent of the primary tumour. The higher the number, the larger the tumour and the more it has grown into nearby tissues.

(ACS 2020)

Node

• NX: Cancer in nearby lymph nodes cannot be measured.
• N0: There is no cancer in nearby lymph nodes.
• N1, N2, N3: There is evidence of cancer in the lymph nodes. The higher the number, the higher the number of lymph nodes affected.

(ACS 2020)

Metastasis

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

(NCI 2015)

As brain tumours generally do not spread outside of the central nervous system, they are described only using the T of the TNM system. There is no single staging system that is available for central nervous system tumours (Cancer.Net 2018).

Cancer Stages

The results of the information gathered are used to determine the stage of the cancer. These stages range from stage zero to stage four.

• Stage 0: These cancers have not spread to any nearby tissue and are still located in the place they started. They can be described as 'cancer in-situ'. This stage of cancer is often highly curable and is usually treated by removing the entire tumour with surgery.
• Stage I: This stage can also be called an early-stage cancer. It is usually a small cancer or tumour that has not grown deeply into nearby tissues and has not spread to any lymph nodes or other parts of the body
• Stages II and III: These cancers may have spread to lymph nodes but not to any other parts of the body. They are larger cancers than stage I cancers and have grown more deeply into the nearby tissues.
• Stage IV: This stage can also be described as advanced or metastatic cancer, as the cancer has spread to other organs or body parts.

(Cancer.Net 2018)

Restaging

Once a cancer is staged, this stage does not change. If the cancer returns, it will have the same stage as the first cancer. Any information about the returning cancer will be added on to the stage.

Restaging is very uncommon and generally only done to determine how well a treatment may be working or to get more information about a cancer that has returned after treatment. If a new stage is determined when this restaging occurs, it is always discussed and documented in conjunction with the old stage (Cancer.Net 2018).

Nursing Implications and Support for the Patient

Because cancer has so many implications for the patient and can cause a variety of negative effects such as pain, fatigue and nausea (just to name a few), nursing care for patients with cancer will vary.

Supporting not only the patient, but also their family and loved ones, is essential. This support can assist in alleviating anxiety and allowing the patient and their loved ones to feel supported and empowered in their decision-making processes.

As well as provide support, nurses also need to monitor and assist with the management of side effects from the cancer and treatments. We need to ensure adverse effects are promptly identified so that management is carried out efficiently to increase the comfort of the patient.

Nurses are at the heart of cancer care and are with patients at each step of the way. Therefore, we can have a significant impact on the cancer experience of the patient and their family. We often provide support, as well as laugh with them, cry with them and be there for them and their families during their journey. Sometimes, nursing care of the individual with cancer can be as simple as giving support to someone through one of the hardest times of their life.

References

• American Cancer Society 2020, Cancer Staging, ACS, viewed 9 November 2020, https://www.cancer.org/treatment/understanding-your-diagnosis/staging.html
• Cancer.Net 2018, Stages of Cancer, American Society of Clinical Oncology (ASCO), viewed 9 November 2020, https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/stages-cancer
• Dillekås, H, Rogers, M S & Straume, O 2019, 'Are 90% of Deaths From Cancer Caused by Metastases?', Cancer Medicine, vol. 8 no. 12, viewed 9 November 2020, https://onlinelibrary.wiley.com/doi/full/10.1002/cam4.2474
• Healthwise 2019, Cancer Staging and Grading, Healthwise, viewed 9 November 2020, https://www.mottchildren.org/health-library/abn1258
• National Cancer Institute 2015, Cancer Staging, National Institutes of Health, viewed 9 November 2020, https://www.cancer.gov/about-cancer/diagnosis-staging/staging