TUMOR STAGING AND GRADING

Cancer Staging
• Stage refers to the extent of your cancer, such as how large the tumor is, and if it has
spread. Knowing the stage of the cancer helps the doctor:
 Understand how serious the cancer is and the chances of survival
 Plan the best treatment for the patient
 Identify clinical trials that may be treatment options for the patient
• 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
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
Doctors use diagnostic tests like biopsies and imaging exams to determine a cancer's grade and
its stage. While grading and staging help doctors and patients understand how serious a cancer is
and form a treatment plan, they measure two different aspects of the disease.
What is a cancer grade?
• A cancer’s grade describes how abnormal the cancer cells and tissue look under a
microscope when compared to healthy cells. Cancer cells that look and organize most
like healthy cells and tissue are low grade tumors. Doctors describe these cancers as
being well differentiated. Lower grade cancers are typically less aggressive and have a
better prognosis.
 • The more abnormal the cells look and organize themselves, the higher the cancer’s grade.
Cancer cells with a high grades tend to be more aggressive. They are called poorly
differentiated or undifferentiated.
Some cancers have their own system for grading tumors. Many others use a standard 1-4 grading
scale.
• Grade 1: Tumor cells and tissue looks most like healthy cells and tissue. These are called
well-differentiated tumors and are considered low grade.
• Grade 2: The cells and tissue are somewhat abnormal and are called moderately
differentiated. These are intermediate grade tumors.
• Grade 3: Cancer cells and tissue look very abnormal. These cancers are considered poorly
differentiated, since they no longer have an architectural structure or pattern. Grade 3
tumors are considered high grade.
• Grade 4: These undifferentiated cancers have the most abnormal looking cells. These are
the highest grade and typically grow and spread faster than lower grade tumors.
What is a cancer stage?
• While a grade describes the appearance of cancer cells and tissue, a cancer’s stage
explains how large the primary tumor is and how far the cancer has spread in the patient’s
body.
• There are several different staging systems. Many of these have been created for specific
kinds of cancers. Others can be used to describe several types of cancer.
Stage 0 to stage IV
• One common system that many people are aware of puts cancer on a scale of 0 to IV.
• Stage 0 is for abnormal cells that haven’t spread and are not considered cancer, though
they could become cancerous in the future. This stage is also called “in-situ.”
• Stage I through Stage III are for cancers that haven’t spread beyond the primary tumor
site or have only spread to nearby tissue. The higher the stage number, the larger the
tumor and the more it has spread.
• Stage IV cancer has spread to distant areas 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—Cancer is limited to the place where it started, with no sign that it has spread.
 Regional—Cancer has spread to nearby lymph nodes, tissues, or organs.
 Distant—Cancer has spread to distant parts of the body.
  Unknown—There is not enough information to figure out the stage.
TNM staging
• Another common staging tool is the TNM system, which stands for Tumor, Node,
Metastasis. When a patient’s cancer is staged with TNM, a number will follow each
letter. This number signifies the extent of the disease in each category. According to the
National Cancer Institute and MD Anderson experts, the standard TNM system uses the
following rules:
Primary tumor (T)
• TX: Main tumor cannot be measured.
• T0: Main tumor cannot be found.
• T(is), or T in situ: The tumor is still within the confines of the normal glands and cannot
metastasize.
• 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)
Lymphatic fluid transports immune system cells throughout the body. Lymph nodes are small
bean-shaped structures that help move this fluid. Cancer often first spreads to and through nearby
lymph nodes.
• 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)
• Metastasis is the spread of cancer to other parts of the body.
• 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.
CANCER DETECTION EXAMINATIONS
1. CYTOLOGIC EXAMINATION or PAPANICOLAU TEST (PAP’S EXAM, PAP SMEAR)
• Cytologic specimen can be obtained from tumors that tend to shed cells from their
surface, e.g., G.I. tract through endoscopy, respiratory tract through laryngoscopy and
 bronchoscopy, genito-urinary tract through colposcopy of the cervix and vagina,
cystoscopy of the bladder, laparoscopy of the pelvic and abdominal cavity.
INTERPRETATION OF PAPANICOLAU TEST RESULTS ARE AS FOLLOWS:
• CLASS I - Normal
• CLASS II - Inflammation
• CLASS III - Mild to moderate dysplasia
• CLASS IV - Probably Malignant
• CLASS V - Possibly Malignant
Discussion:
• CLASS I result requires follow – up examination every 1 to 3 years as recommended by
the physician
• CLASS II and III results may require repeat Pap exam in 3 to 6 months as prescribed
• CLASS IV and V results require biopsy as prescribed
2. BIOPSY– involves obtaining tissue samples by needle aspiration, or incision of tumor.
• Needle biopsy is done by aspiration of tumor cells with needle and syringe
• Excisional biopsy is done by removing the entire tumor. It is done when the tumor is
small.
• Incisional or subtotal biopsy is done by taking only a part of the tumor. The is done when
the tumor is large.
3. Ultrasound
• Magnetic Resonance Imaging (MRI),
• Radio diagnostic Test (e.g. X-RAYS, Mammography)
• Computed Tomography (CT Scan),
• Endoscopic Examinations
4. LABORATORY BLOOD TESTS FOR CANCER
• HEMATOLOGIC (CBC)
• Hemoglobin
• Hematocrit
• Leukocytes
• Platelets
TUMOR MARKERS
• AFP (Alpha – Feto – Protein)
• CEA (Carcinoembryonic Antigen)
• HCG (Human Chorionic Gonadotropin)
• Prostatic Acid Phosphatase
• PSA (Prostatic Specific Antigen)
• Hemoglobin and Hematocrit are low in anemia; may indicate malignancy
Discussion:
• Leukocytes (WBC’s) are high in leukemia (immature WBC’s), lymphomas;
• low in leukemia (mature WBC’s) and metastatic disease to bone marrow.
• Platelets are high in CML (Chorionic Myelocytic Leukemia), Hodgkin’s disease;
• low in ALL (Acute Lymphocytic Leukemia), AML (Acute Myelocytic Leukemia),
Multiple Myeloma, bone marrow depression.
• AFP is elevated in lung, testicular, pancreatic, colon, gastric cancers, and
choriocarcinoma
• CEA is elevated in colorectal, breast, lung, stomach, pancreatic, and prostate cancers
• HCG is elevated in choriocarcinoma, germ cell testicular cancer, ectopic production in
lung, liver, gastric, pancreatic, and colon cancers.
• Prostatic Acid Phosphatase is elevated in metastatic prostate cancer. PSA is elevated in
prostate cancer.
NURSING DIAGNOSES
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalanced nutrition: less than body requirements
• Risk for imbalanced fluid volume
• Anxiety
 • Disturbed body image
• Deficient knowledge
• Ineffective coping
• Social isolation
OUTCOME IDENTIFICATION
1. Pain relief
2. Integrity of skin and oral mucosa
3. Absence of injury and infection
4. Fatigue relief
5. Maintenance of nutritional intake and fluid and electrolyte balance
6. Improved body image
7. Absence of complications
8. Knowledge of prevention and cancer treatment
9. Effective coping through recovery and grieving process
10. Optimal social interaction
IMPLEMENTATION/MANAGEMENT
• Prevention and detection
– Primary Prevention
• Reducing modifiable risk factors in the external and internal environment
– Secondary Prevention
• Recognizing early signs and symptoms and seeking prompt treatment
• Prompt intervention to halt cancerous process
– Tertiary Prevention
• focus on monitoring and preventing recurrence of the primary cancer as
well as screening for development of second malignancies in cancer
survivors.
• Chemotherapy
• Radiation therapy
Cancer Prevention
Discussions:
• Since exposure to carcinogens (cancer-causing agents) is responsible for triggering most
human cancers, people can reduce their cancer risk by taking steps to avoid such agents.
• Hence the first step in cancer prevention is to identify the behaviors or exposures to
particular kinds of carcinogens and viruses that represent the greatest cancer hazards.
Avoid Tobacco
Discussions:
• As the single largest cause of cancer death, the use of tobacco products is implicated in
roughly one out of every three cancer deaths.
• Cigarette smoking is responsible for nearly all cases of lung cancer, and has also been
implicated in cancer of the mouth, larynx, esophagus, stomach, pancreas, kidney, and
bladder. Pipe smoke, cigars, and smokeless tobacco are risky as well.
• Avoiding tobacco is therefore the single most effective lifestyle decision any person can
make in attempting to prevent cancer.
Protect Yourself From Excessive Sunlight
Discussions:
• While some sunlight is good for health, skin cancer caused by excessive exposure to
sunlight is not among the sun’s benefits. Because some types of skin cancer are easy to
cure, the danger posed by too much sunlight is perhaps not taken seriously enough.
• It is important to remember that a more serious form of skin cancer, called melanoma, is
also associated with excessive sun exposure. Melanomas are potentially lethal tumors.
Risk of melanoma and other forms of skin cancer can be significantly reduced by
avoiding excessive exposure to the sun, using sunscreen lotions, and wearing protective
clothing to shield the skin from ultraviolet radiation.
Limit Alcohol and Tobacco
Discussions:
• Drinking excessive amounts of alcohol is linked to an increased risk for several kinds of
cancer, especially those of the mouth, throat, and esophagus. The combination of alcohol
and tobacco appears to be especially dangerous.
• For example, in heavy smokers or heavy drinkers, the risk of developing cancer of the
esophagus is roughly 6 times greater than that for nonsmokers/nondrinkers. But in people
who both smoke and drink, the cancer risk is more than 40 times greater than that for
nonsmokers/nondrinkers.
 • Clearly the combination of alcohol and tobacco is riskier than would be expected by just
adding the effects of the two together.

Diet: Limit Fats and Calories

Discussions:
• Studies suggest that differences in diet may also play a role in determining cancer risk.
Unlike clear-cut cancer risk factors such as tobacco, sunlight, and alcohol, dietary
components that influence cancer risk have been difficult to determine.
• Limiting fat consumption and calorie intake appears to be one possible strategy to
decrease risk for some cancers, because people who consume large amounts of meat,
which is rich in fat, and large numbers of calories exhibit an increased cancer risk,
especially for colon cancer.
Diet: Consume Fruits and Vegetables
Discussions:
• In contrast to factors such as fat and calories, which appear to increase cancer risk, other
dietary components may decrease cancer risk.
• The most compelling evidence has been obtained for fruits and vegetables, whose
consumption has been strongly correlated with a reduction in cancer risk.
• Although the exact chemical components in these foods that are responsible for a
protective effect are yet to be identified, eating five to nine servings of fruits and
vegetables each day is recommended by many groups.
Avoid Cancer Viruses
Discussions:
• Actions can also be taken to avoid exposure to the small number of viruses that have been
implicated in human cancers. A good example is the human papillomavirus (HPV).
• Of the more than 100 types of HPVs, over 30 types can be passed from one person to
another through sexual contact. Among these, there are 13 high-risk types recognized as
the major cause of cervical cancer.
• Having many sexual partners is a risk factor for infection with these high-risk HPVs,
which can, in turn, increase the chance that mild cervical abnormalities will progress to
more severe ones or to cervical cancer.
Avoid Carcinogens at Work
Some Carcinogens in the Workplace

Discussions:
• Because people spend so much time at work, potential carcinogens in the work
environment are studied carefully. Some occupational carcinogens have been identified
because coworkers exposed to the same substances have developed a particular kind of
cancer at increased frequency.
• For example, cancer rates in construction workers who handle asbestos have been found
to be 10 times higher than normal.
Industrial Pollution
Discussions:
• The fact that several environmental chemicals can cause cancer has fostered the idea that
industrial pollution is a frequent cause of cancer. However, the frequency of most human
cancers (adjusted for age) has remained relatively constant over the past half-century, in
spite of increasing industrial pollution.
• So, in spite of evidence that industrial chemicals can cause cancer in people who work
with them or in people who live nearby, industrial pollution does not appear to be a major
cause of most cancers in the population at large.