What is Meant by Cancer Staging? Learn the Language of a Cancer Diagnosis

Cancer staging is very important to guide treatment decisions and eligibility in studies. When an oncologist delivers a diagnosis it will include stage, but what does that mean? After an agonizing period of tests, waits for results, and finally an answer, many people go numb as soon as they hear the word "cancer" and fail to ask for clarification about terminology. Learn what you need to know to be an active participant in your care. Show Notes: https://bit.ly/41q519X

In this Episode:

• 01:45 - Recipe: Alabama Lane Cake, featured in "To Kill a Mockingbird"
• 03:13 - A Short Guide to a Happy Life by Anna Quindlen
• 07:23 - What You Need to Know About Cancer Staging
• 09:48 -  The Exceptions to Staging
• 11:02 - Understanding Staging with a Stomach Cancer Example
• 18:11 - Cancer Staging Sub-Categories
• 20:44 - TNM Categories
• 24:15 - Discussion - Thoughts About Stage 4
• 30:22 - A Letter Attributed to David Bowie, Who Died from Liver Cancer
• 32:57 - Outro

What is Cancer Staging?

Our focus today is to help you understand the cancer staging system. The stage of disease measures if the cancer has spread, and how far is has spread from where it started.  Cancer staging is a way to communicate the extent of cancer in the body so that everyone involved is speaking the same language.

Cancer Staging Example: Stomach Cancer

Dr. Matzo used stomach cancer as a way to understand staging. Visit our show notes for an image and detailed explanations.

Marianne also shared about cancer sub-categories, such as 1a, 2c, etc. This further refines the definition of how far the cancer has spread.

Cancer Staging with TNM Categories

The Tumor-Node-Metastasis notation is an even more refined way to define the extent of cancer spread. TNM helps to establish the anatomic extent of the disease, and the combination of the 3 factors can define the overall tumor stage. This method allows for simplification, with cancers staged from I-IV, with stage IV being the most severe stage. 

Related Episodes:

• S5E45: Why Does Cancer Exist? Empower Yourself With Understanding
• S5E46: “Why Do I Have Cancer?” Kismet, Chastisement or Coincidence?
• S5E47: MythBusters – Cancer Edition; Clarifying Common Cancer Myths & Misconceptions
• S5E48: How to Read a CT Scan Report – Learn the Sections Relevant to Your Diagnosis
• S5E49: Are there Miracle Cures for Cancer? With Dr. Jeanna Ford
• S4E46: What You Need to Know about Stomach Cancer – Part 1
• S4E47: What You Need To Know About Stomach Cancer, Part 2

Chapters

• 0:00 Intro
• 1:45 Recipe: Alabama Lane Cake, featured in “To Kill a Mockingbird”
• 3:13 A Short Guide to a Happy Life by Anna Quindlen
• 7:23 What You Need to Know About Cancer Staging
• 9:48 The Exceptions to Staging
• 11:02 Understanding Staging with a Stomach Cancer Example
• 18:11 Cancer Staging Sub-Categories
• 20:44 TNM Categories
• 24:15 Discussion – Thoughts About Stage 4
• 30:22 A Letter Attributed to David Bowie, Who Died from Liver Cancer
• 32:57 Outro

Transcript

Hello and welcome to Everyone Dies, the podcast where we talk about serious illness, dying, death, and bereavement. I'm Marianne Matzo, a nurse practitioner, and I use my experience from working as a nurse for 46 years to help answer your questions about what happens at the end of life. And I'm Charlie Navarette, an actor in New York City, and here to offer an every-person viewpoint to our podcast.

We are both here because we believe that the more you know, the better prepared you are to make difficult end-of-life decisions. Also, this podcast does not provide medical nor legal advice. Please listen to the complete disclosure at the end of the recording.

Welcome to this week's show. Please relax, get yourself a handful of something sweet, or something healthy, or both, and thank you for spending the next hour with Charlie and me as we continue with our series titled, Everything You Always Wanted to Know About Cancer, But Didn't Have Anyone to Ask, with a conversation about how cancer is staged. Like the BBC, we see our show as offering entertainment, enlightenment, and education, and divide that into three halves to address each of these goals.

Our main topic is in the so feel free to fast forward to that loose-lip, free zone. In the first half, Charlie has our recipe of the week and an excerpt from Anna Quinlan's A Short Guide to a Happy Life. In the second half, I'm going to continue our cancer series with a discussion about what it means when you hear the staging of a cancer diagnosis.

And in the third half, Charlie has a letter attributed to David Bowie. In our first half, the Everyone Dies Road Trip takes us to the state where Rosa Parks sparked the Montgomery Bus Boycott in Montgomery, Alabama in 1955. Alabama's official state dance is the Square Dance and holds the world record for the most barbecue-smoked pork sandwiches made in one hour.

Alabama Lane Cake is said to have originated in Clayton, Alabama, when its creator, Emma Rylander Lane, won a prize for it in the state fair. It's a sweet concoction of white sponge cake, pecans, bourbon-soaked raisins, cherries, and coconut. It's the state's official dessert and gets a mention in Harper Lee's classic To Kill a Mockingbird.

The novel makes reference to the cake when Atticus's sister, Miss Maudie, comes to stay with the family. The reference highlights how Miss Maudie won't share her special recipe and isn't shy when pouring in the liquor. Young Scout mentions that Miss Maudie Atkinson baked a Lane Cake so loaded with shinny, it made me tight.

And now you, our loyal listeners, can prepare this cake for your next funeral lunch and everyone in attendance can feel tight. Bon Appetit! And now for something completely different. I have an excerpt from the book A Short Guide to a Happy Life by writer Anna Quindlen, the best-selling novelist and columnist.

In it, she reflects on what it takes to get a life, to live deeply every day and from your own unique self, rather than merely to exist through your days. I'm not particularly qualified by profession or education to give advice and counsel. It's widely known in a small circle that I make a mean tomato sauce and I know many inventive ways to hold the baby while nursing, although I haven't had the opportunity to use any of them in years.

I have a good eye for a nice swatch and a surprising paint chip, and I have a checkered but occasionally successful sideline in matchmaking, but I've never earned a doctorate or even a master's degree. I'm not an ethicist or a philosopher or an expert in any particular field. Each time I give a commencement speech, I feel like a bit of a fraud.

Yogi Berra's advice seems as good as any. When you come to a fork in the road, take it. I can't talk about the economy or the universe or academe as academicians like to call where they work when they're feeling kind of grand.

I'm a novelist. My work is human nature. Real life is really all I know.

Don't ever confuse the two, your life and your work. That's why I have to say the second is only a part of the first. Don't ever forget what a friend once wrote to Senator Paul Zongas when the senator had decided not to run for re-election because he'd been diagnosed with cancer.

No man ever said on his deathbed, I wish I had spent more time at the office. Don't ever forget the words on a postcard that my father sent me last year. If you win the rat race, you're still a rat.

Or what John Lennon wrote before he was gunned down in the driveway of the Dakota. Life is what happens to you while you're busy making other plans. That's the only advice I can give.

After all, when you look at the faces of a class of graduating seniors, you realize that each student has only one thing that no one else has. When you leave college, there are thousands of people out there with the same degree you have. When you get a job, there will be thousands of people doing what you want to do for a living.

But you are the only person alive who has sole custody of your life, your particular life, your entire life. Not just your life at a desk, or your life on the bus, or in the car, or at the computer. Not just the life of your mind, but the life of your heart.

Not just your bank account, but your soul. Please go to our webpage for this week's recipe for Alabama Lane Cake and additional resources for this program. Everyone Dies is offered at no cost, but is not free to produce.

Can we count on you to contribute? Your tax-deductible gift will go directly to supporting our non-profit journalism so that we can remain accessible to everyone. You can also donate at www.everyonedies.org or at our site on Patreon, www.patreon.com, and search for Everyone Dies. And our address again, www.every-the-number-one-dies.org. Marianne? Thanks Charlie.

All cancer diagnoses follow pretty much the same path. If you go to your healthcare practitioner with any symptom, they will typically do a physical exam, blood and urine tests to see if there are any abnormalities, perhaps an x-ray, CAT scan, or MRI to look at your organs and bones, and possibly a biopsy of the area to look at the cells. Our focus today is to help you understand the cancer staging system.

Cancer staging is a way to communicate the extent of a cancer in the body so that everyone involved is speaking the same language, but it's often not clearly explained to the person receiving the information. I've had patients tell me how glad they are that their cancer is only a stage 4. My next question to them is, how many stages are there? Likely because we are familiar with base 10 system, they tell me 10 stages. Usually they then look at me and say, right? And I say, no, there are four stages.

Which after that sinks in, they realize the severity of stage 4 cancer diagnosis. Since I don't want that to happen to you, let's go over the stages. The stages of disease measures how far cancer has spread from where it started.

So for purposes of our talk, let's say someone is being evaluated for stomach cancer. So if we're looking at spread from the origin, we want to know how far the cancer has spread outside of the stomach. The staging system used by the Centers for Disease Control and Prevention and the National Cancer Institute is called summary stage.

Summary stage categorizes cancers as localized, regional, or distant. Localized stomach cancer is confined to the stomach. Regional cancer has spread directly beyond the stomach, called regional extension, or to regional lymph nodes.

The distant cancer has spread to other organs besides the stomach, distant extension, or to remote lymph nodes. Most cancers are staged except for just a couple exceptions. The first exception is liquid tumors.

These are blood cancers and leukemias. Because they're already circulating through the entire body, they are described as active or in remission. The second exception are brain tumors because they may have spread to other parts of the central nervous system.

They rarely spread to organs or to lymph nodes or other parts of the body. Instead, the tumor cells are graded from one to four to describe how different they look from normal cells. Grade four cells look the most abnormal.

And the third is small cell lung cancer is usually described simply as either limited stage or extensive stage. Limited stage disease means the cancer is confined to the chest. Extensive disease means it's extended outside the chest.

Other than that, cancer stages go from zero to four. Our organs are made up of multiple cell layers all stacked on top of each other. Think of it like a seven layer dip except you can't stir all the layers together.

So let's continue to look at the stomach as an example. The mucosa is the innermost layer of the stomach wall. When we eat, the food coasts along the mucosa.

The mucosa is made of both epithelial cells and glandular cells. The glandular cells make mucus to protect the stomach lining and digestive juices to help break down food. Most stomach cancers start in glandular cells of the mucosa and are called adenocarcinomas.

Cancer found in this area only is stage zero. So stage zero, you might also hear it referred to as carcinoma in situ, is stage zero or you might also hear it referred to as carcinoma in situ of the stomach. This means that abnormal cells are found only in the mucosa.

These abnormal cells may become cancer and spread into nearby normal tissue. It also might be called high-grade dysplasia of the stomach, meaning that there are several abnormal cells in the inner lining of the stomach. So that's stage zero.

The next layer of the stomach is called the submucosa or right under the mucosa and it is the layer of connective tissue between the mucosa and the muscle layer. It contains blood vessels, lymph vessels, and nerve cells. Under that is the muscle layer.

The muscle layer flexes and helps the stomach mix food with digestive juices and move it into the small intestine where the nutrients are absorbed. So this is where this is the area where you'll see stage one or localized stomach cancer. Stage one stomach cancer usually means that the cancer hasn't spread beyond the thick muscle of the stomach wall but may have moved to one or two nearby lymph nodes.

Now to remind you, lymph nodes are small bean-shaped structures that are part of the body's immune system. Lymph nodes filter substances that travel through the lymphatic fluid and they contain the white blood cells that help the body fight infection and disease. Now there are hundreds of lymph nodes or you might hear them called lymph glands found throughout the body.

They're all connected to one another by lymph vessels. So if you think of like a bunch of grapes that are all hanging on the vine. Clusters of lymph nodes are found in the neck, under your arm, chest, abdomen, groin.

For example, there are about 20 to 40 lymph nodes in the armpit alone. There are approximately 600 lymph nodes in your body as an adult. So stage two called locally advanced cancer or early stage cancer, this means that the cancer has spread into and through the muscle layer of the stomach and it might have spread into 15 nearby lymph nodes.

So you can see how this is going. If it stays right in the inner lining, that mucosa, it's a zero. You know, it hasn't grown, it hasn't moved.

And then stage one, it's moving but it hasn't gone beyond the thick muscle. Stage two, it's gone through the muscle and also into lymph nodes. So the next layer after the muscle is called the sub serosa, which is a thin layer of connective tissue between the muscle layer and the wall, the outer wall of the stomach, which is the serosa.

You know when you take the skin off of a chicken and you see those white strands connecting the chicken skin to the chicken meat, that's the sub serosa. Last is the serosa, which is the outermost layer of the stomach wall. It's the outside of the organ.

So if you were to pick up the stomach and hold it in your hand, what's laying against your hand is the serosa. So stage three, locally advanced cancer or late stage cancer, means that the cancer has grown into or through the muscle or the outer layer, the stomach wall of the stomach. It might have spread to 16 or more lymph nodes or the cancer has spread to nearby organs such as the spleen, colon, the liver, the diaphragm, the pancreas, the abdomen wall, the adrenal gland, the kidney, or small intestines, or the back of the abdomen.

So that's stage three, locally advanced. And the final stage is stage four, and this is called metastatic, in our case, stomach cancer. Stage four stomach cancer has spread into nearby organs or body structures.

It's spread to distant body parts such as the lung, liver, distant lymph nodes, and the tissue that lines the abdomen wall. Metastatic cancer happens when cancer cells travel through the lymphatic system or blood and form tumors in other parts of the body. The metastatic tumor is the same type of cancer as the primary tumor.

For example, if stomach cancer spreads to the lung, the cancer cells in the lung are actually stomach cancer cells. The disease is called metastatic stomach cancer, not lung cancer. And just when you thought you might have a handle on cancer staging, I need to add that each of these stages, one through four, are then further broken down into three categories, A, B, or C. These are further details about the stage, and there is a link in the show notes where you can see how detailed this part of the category becomes.

I'm only going to give you an example because it's mind-boggling. So as an example, if the diagnosis is stage 1A, a cancer is formed in the mucosa and may have spread to the submucosa. But if the cancer is stage 1B, that means the cancer is formed in the mucosa, may have spread to the submucosa, and has spread to one or two nearby lymph nodes, or the cancer has formed in the mucosa and has spread to the muscle layer.

So look at the reference for these final points because they're hard to follow without really seeing them in writing. But I want you to know how detailed cancer staging is. And, I mean, I've seen this news being given to patients where they say, well, you have stage 3C stomach cancer.

And all you really hear at that point is you've got cancer and it's in your stomach. 3C, what I see is very few patients stop and say, so wait a minute, what does that mean? Because their mind is like too worried and concerned about the fact that it's a cancer diagnosis. But then you then get home and you say, well, I'm going to Google this and it's really hard to understand.

So that's why I wanted to break it down for you as much as I could. So look at those references and it might help you too with the A, B, and C part. Now, lastly, there's a classification system called TNM.

The way oncologists talk about tumor categories is called TNM, which stands for the T is tumor, and that describes the size of the primary tumor and its invasion into nearby tissues with the ranges of zero to four. The N part is node, which is lymph node involvement of the tumor and ranges from zero, no lymph node spread, to three, which is seven or more regional lymph nodes involved. And the M part is when the tumor is—stands for metastasis, which is when the tumor spreads beyond the primary organ.

A tumor is classified as M0 if no distant metastasis is present, and M1 if there's evidence of distant metastasis. So a classification of T3, N2, M0—I'll say it three part. There are four to six regional lymph nodes involved, the N2 part, and no metastasis, the M0 part.

What that would translate to if you were looking at the staging system is that T3, N2, M0 corresponds to stage two locally advanced cancer late stages. I know this is a lot to take in, but this is the language of cancer. And if you know someone with cancer, it's useful for you to have at least a basic understanding of what is being said.

Be sure to look at the show notes, especially if you learn things better by seeing them. You can listen to this again, look at the references where you can also see all of this that I'm talking about, but it gives you a way to at least have a beginning understanding of, well, first off, I guess, how complicated cancer staging is, how detailed it is, because each of these stages correspond to what treatment is going to be recommended. And we'll talk about that part in a different podcast.

But right now, this is cancer staging. Charlie, got any questions? Well, Marianne, I'll never look at a chicken the same way again. But yeah, your description of those.

Yeah, and I'm just sitting here thinking because I had chicken last night. And yeah, those little stringy things. You said about not feeling anything.

Yeah, I mean, I've read about things, you know, people feeling fine, then one day they don't feel fine. And they've had cancer, it's grown, it really can't be treated. And they die maybe, you know, a few weeks later.

Because as you were saying, you know, they're like, you know, four levels. And at four levels, you know, most people feel something in their body changing, they go to the doctor, and then the doctor says, yeah, you have cancer, let's see what we can do about it. And other times, by that time, it can't be treated.

Or it's just very difficult to treat it. Am I making sense? Well, stage four cancer, while it can't be cured, they may do interventions to slow it. They may have clinical trials that you can be involved in.

Okay. There are some people who it's so widely metastasized, I mean, it's gone to so many places that it's very rare for, let me put it this way, it's very rare for an ecologist not to offer something. Then the question becomes, what are you trading off for that something? Because, and we'll talk about chemotherapy, and we'll talk about surgery, and we'll talk about radiation.

You know, a lot of things can be done. The question might be, should it? Should that be something that, or is it something that you want to spend your time doing? And the question then becomes asking the oncologist, well, okay, so if I do this, what can I expect for increasing the length of my life? And we know from the research that, you know, depending on the intervention and depending on the type of cancer, it might be an additional three days. Okay.

You know, because they do studies. So then you look at it and you say, okay, well, I've got to drive to the cancer center. I have to have a port put in.

I have to do this. I have to do that. And I'm extending my life three days, but I'm giving up all these other days to go do this intervention.

And some people might say, that's just not worth it. Some people might say, I'll do anything for those extra three days. So it's a question of your values and that kind of thing.

But hopefully as people listen to this and they, you know, hear about the symptoms of cancer or that kind of thing that they say, oh, you're losing an awful lot of weight. You're not trying. Have you gone to talk to your doctor? You know, or we've done shows on ovarian cancer that's diagnosed very late because women and their doctors will say, oh, well, it's normal.

You're getting older. Yeah. You know, your belly's getting a little bit bigger, but you know, watch what you're eating when in fact it's ovarian cancer.

So our point in being here is to say to people, here are the early signs of these things. And it should be a red flag for you to go in to your doctor and say, here's what I think or here's what I'm wondering. You know, you mentioned Paul Songhas in Anne and Quinlan's thing.

I don't know if you remember when I lived in Lowell, Paul Songhas lived right next door to me. Oh, that's right. Sure.

Yeah. Yeah. He was diagnosed with cancer because, well, not because, but he was taking a shower and he felt his lymph nodes under his armpit.

He was like, what's this? And he went to the doctor and that's how he was diagnosed as opposed to blowing it off and saying, I don't know. So it's a question of knowing your body, knowing something's different and not being, you know, we did this show about gaslighting, remember? Right, right. And you know, people go to the doctor and sometimes the doctor will say, well, and you know, and you're gonna say, well, no, no, I don't agree with that.

I really think that I should get a CAT scan or something because I'm really concerned about this. If you're really concerned about it, don't put your head in the sedan and, you know, insist that you want to be evaluated. Yeah.

Advocate for yourself. Absolutely. Okay.

Well, thank you for edumacating me, Marianne. That's very clear now. Even I get it.

So, okay. Thank you. My pleasure.

For our third half, a letter attributed to David Bowie, who died on January 10, 2016 from liver cancer at age 69. I will die. I know there are only a few months left until the end of my earthly journey.

What should I do? Despair, sink into depression, reject the idea of death, and pretend the illness doesn't exist? Or should I decide to defeat death? I decided with my soul because only the soul and the heart give me the inspiration to compose music, as I've done for 50 years. I count the hours I have left. And as the doctors tell me, I can predict within a certain margin, the date of my death.

The release of my last work is scheduled for January 8, 2016, my 69th birthday. I work day and night. I have the time to compose, perfect, perform, record in the studio, and make videos.

I do it as quickly as possible because I don't want my face to show the mark of death, which mockingly is cutting down my body without me being able to defend myself. But I challenge you, death. The hell with it if I don't challenge you.

I challenged and conquered the world of fans in the 70s with a pride of ambiguity. I loved men and women. I was a man, a woman, an alien, and finally, a celestial body.

What can you do, death, against my eternity, my genius, my madness, my creativity, my music that will last forever? I am Lazarus, torn from the scars. I will die in the body, but I will live forever through my music. I lived long enough to receive birthday wishes.

I thought I would have made it to see my album released. I survived January 8, and you, my dear killer, lost. Just think if you hadn't knocked on my door.

I would have created 24 works. I would have managed to live to 100, and instead, thanks to you, I have 25. You know, I will be free as a bird.

And folks, that's it for this week's episode. Please stay tuned for the continuing saga of Everyone Dies, and thank you for listening. This is Charlie Navarrete, and from David Bowie, confront the corpse at least once.

The absolute absence of life is the most disturbing and challenging confrontation you will ever have. And I'm Marianne Matzo, and we'll see you next week.