A. The stage of a cancer can range from 0-IV. Stage is a term that describes the extent of cancer spread. Cancer staging is based on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the local area or organ.

Doctors and nurses use a system called the "TNM" system in order to define the extent of cancer spread.

Q. What does "TNM" stand for?

A. In this system, T stands for tumor size (Figure 1), N stands for lymph nodes involved, and M stands for metastasis, or cancer spread to other organs.

Figure 1: Tumor Size Scale

Q. Why is staging helpful?

A. Staging is useful in the following ways:

* It will help determe your choice of treatment.
* Staging estimates your prognosis (the most likely outcome of the disease).
* Staging provides a universal common language with which doctors, nurses and patients may understand the extent of cancer and the response of that cancer to treatment.

Q. How is staging performed?

A. We know that the stage of a cancer is based on the type of tumor, the size of the tumor, whether or not lymph nodes are involved, and whether or not cancer has spread beyond the primary site or organ to adjacent organs or distant organs such as the bone, liver, brain or lungs.

· The type of cancer (either in situ or invasive) is determined at the time of the tumor biopsy or surgical procedure. Many specific characteristics of the tumor are noted at the time of a biopsy; specific tests are run on the tumor by the laboratory. These tests provide particular specific information about the tumor and thus treatment.

· Tumor size may be measured by physical exam and by imaging studies such as x-rays, computerized tomography (CT) scan, mammogram, or ultrasound. These different imaging studies may be crucial in determining whether or not cancer has spread locally or traveled to distant organs (metastasized).

· A chest x-ray (CXR) may reveal whether cancer calls have spread to your lungs.

· Additional imaging tests. Additional imaging can be used to look for cancer cells that have spread to other areas of your body. Not everyone with cancer needs these tests, though, so ask your doctor what's best for you. Additional imaging tests include a bone scan, computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET).

· In order to further determine the extent of cancer, your surgeon may need to evaluate your lymph nodes. The different organs of the body receive and then drain lymphatic fluid. This fluid drains to lymphatic basins. Depending on which organ has cancer, different lymph-containing areas of the body will need to be explored.

Q. What is important about the lymphatic system of the body?

A. In some types of cancer, cancer cells may travel from certain organs to lymph nodes. Once tumor cells travel to these lymph nodes, the stage of the cancer is more advanced. Physical examination may reveal an abnormal lymph node. Similarly, an abnormality noted on imaging may indicate that further evaluation of a lymph node is indicated. Your doctor will tell you if your type of cancer tends to travel to lymph nodes and if so, if lymph node evaluation is needed.

Q. How might my doctor evaluate the lymph nodes?

A. Knowing whether or not cancer cells have traveled from an organ to the lymph nodes is very important. Below are some ways your surgeon may evaluate the lymph nodes.

* Fine Needle Aspiration (FNA) of a Lymph Node

A needle is inserted into a lymph node that feels enlarged or abnormal. Cells are withdrawn and looked at under a microscope so see if they are malignant, or cancerous.

* Sentinel Lymph Node Biopsy.

This procedure is done to evaluate lymph nodes in several types of cancers, such as melanoma and breast cancer. In this operation, your surgeon removes only the “sentinel” nodes. These are the nodes that are the first to receive and harbor cancer cells. If no cancer is found in the sentinel node(s), you may be spared a more invasive staging procedure in which additional nodes are removed.

* Completion Lymph Node Dissection

In some types of cancer, your surgeon may need to look at the lymph nodes of an area such as the armpit, or neck, or groin, in greater detail, to look for cancer spread. This gives you and your doctor a more accurate measure of the extent of the spread of the cancer.

Q. What does it all mean? When should all this staging be done?

A. The staging process begins at the time of your cancer diagnosis. The amount of time and the number and type of procedures required to complete the staging process will vary depending on your type of cancer. Sometimes it may take several weeks before you know your final cancer stage, and it may require several procedures to gain all the information required to accurately stage your cancer.

The treatment plan will then be tailored to you and your stage of cancer. Your surgeon will refer you to specialists for additional treatments depending on the type and stage of cancer. Depending on tumor type and stage, you may need chemotherapy, surgery, or radiation first. Your doctor will guide you.

Your doctor and his or her whole health care team are prepared to address all of your questions. Keep a list of questions as you go through different tests and treatments; it is a good idea to ask questions as they arise.

It is important to be hopeful, and to know that even the more advanced stages of cancer may be very treatable.

For further staging information, you may consider going to the following website, or to a website recommended by your doctor:

http://www.cancerstaging.net