Staging may be used by your doctor to describe the size of your tumour and how far it has spread within your body.
A commonly used method to describe cancers is the TNM staging system. However, not all cancers are staged using this method. Depending on the type of cancer you have your doctor may use other staging systems to describe your cancer. Ask your doctor to explain these to you.
TNM staging system
The TNM system describes:
- the size of your original (primary) tumour and if it has grown into any of your nearby tissues
- whether any cancer cells have spread from your primary tumour to nearby lymph nodes
- if there are any metastases (when cancer spreads to other parts of your body)
Each stage has numbers and letters that are used to categorise your cancer more specifically.
T in TNM stagingThe T in the TNM system stands for tumour. This part of the staging system generally describes the size or growth of your original tumour.
- TX may be used if your tumour can’t be evaluated.
- T0 means there is no evidence of a tumour.
- Tis or Cis (tumour or cancer in situ) means your tumour is in one small area, usually in the uppermost layer of tissue and hasn’t spread yet.
- T1 to T4 refer to the size of your tumour and how much it has spread into your nearby tissues. The higher the number, the larger your tumour and the more likely it has grown into your nearby tissues.
N in TNM stagingThe N in the TNM system stands for lymph nodes. Your lymph nodes are glands throughout your body that are part of your immune system. This part of staging describes whether or not your cancer has spread to any nearby lymph nodes.
- NX may be used if your lymph nodes can’t be evaluated.
- N0 means there are no cancer cells in your lymph nodes.
- N1 to N3 refer to either how many lymph nodes your cancer has spread to or the position of the nodes in relation to your primary tumour. The higher the number, the more lymph nodes may be affected.
M in TNM stagingThe M in the TNM staging system stands for metastasis. It describes whether or not your cancer has spread to other parts of your body.
- MX may be used if metastasis can’t be evaluated.
- M0 means your cancer has not spread to any other parts of your body.
- M1 means your cancer has spread away from your primary tumour and into one or more other areas of your body.
It’s important to remember that the numbers and letters for each type of cancer don’t mean the same thing. The TNM combinations correspond to four stages. When your doctor has worked out T, N and M of your cancer they will combine them to get an overall stage of your cancer.
It can be a bit confusing because across different forms of cancer, the same TNM code can indicate a different stage of cancer. So, as an example, if you have colon cancer and your TNM is T3 N0 M0, your cancer will be at stage two. However, this combination corresponds to stage three in bladder cancer. Ask your doctor to explain anything you’re unsure about.
Dukes staging system
The Dukes staging system is a lettered (A-D) system and may be used to describe bowel cancer.
- Dukes A means your tumour is contained within the wall of your bowel.
- Dukes B means your tumour has grown into the muscle of your bowel wall.
- Dukes C means one or more of your lymph nodes near your bowel are affected.
- Dukes D means your original tumour has spread to other parts of your body.
Doctors may talk about the Dukes staging system, but it’s worth knowing that it’s an older system. If your doctor uses the Dukes staging system, you may want to ask if it can be translated into the TNM staging system. This is because it’s gradually being replaced by the TNM staging system as it provides more information about your cancer.
TNM and Dukes are the main staging systems, but other cancers, such as those that affect your blood or brain are staged differently.
Grading is used to describe what your tumour looks like under a microscope so your doctor can get an idea of how it may progress. A low grade cancer cell looks like a normal cell and is likely to grow more slowly. A high grade cancer cell looks abnormal and is more likely to grow and spread faster.
If you have cancer, your doctor will take a sample of cells from your tumour (a biopsy) to send to a laboratory for testing. The cancerous cells will be looked at under a microscope to see how your tumour may grow.
There are four grades used to rate cancer. These are described below.
- Grade 1 or low grade cancer is slow growing. The cancer cells look very much like healthy cells in your body.
- Grade 2 or intermediate grade cancer grows slightly faster. The cancer cells look different from healthy cells in your body.
- Grade 3/4 or high grade cancer is fast growing. The cancer cells look very different from healthy cells in your body.
If you have a high grade cancer, you may need different treatment than if you have a low grade cancer. Even though the grade doesn’t change a cancer’s stage, it may still affect your treatment.
If you’re unsure about how your cancer may be graded or need more information, ask your doctor.
The Gleason scoring system is used to grade prostate cancer.
Your cancer cells are graded one to five, according to the pattern of cells under the microscope. Grade one cells look like normal prostate cells, whereas grade five cells look very different to normal prostate cells. A Gleason score is worked out by adding together the most common grade and the highest grade of what is left in your sample.
Your combined Gleason score will normally be six or higher. It’s rare to get a score lower than six as grade one and two are not cancer.
The Nottingham grading system is used to grade breast cancer based on:
- if your tumour has any normal structures within it
- the size and shape of your tumour
- how fast your tumour is growing
These three factors each get a score between one and three. The scores are then added together to give you a total score between three and nine. From this, three grades are possible.
- Low grade – a score between three and five.
- Intermediate grade – a score between six and seven.
- High grade – a score between eight and nine.
Can I have a high stage with a low grade or vice versa?
Yes, this can happen as the stage and grade of your cancer are two different things.
The stage of your cancer is a description of the size of your tumour and how far it may have spread in your body. For example, if your cancer is at an advanced (high) stage, it may mean you have it in more than one place in your body. Whereas, the grade of your cancer is a description of what your tumour looks like under a microscope and how it’s likely to develop. If your cancer is slow growing, it may be described as low grade.
If you have a slow-growing cancer, it can be found at either an early (low) stage before it has spread or at an advanced stage. For example, non-Hodgkin's lymphoma can be low grade but found at an advanced stage. This means the cancer is in more than one place in your body, but the cells look very similar to your healthy cells – so it’s slow-growing.
It’s possible to have cancer that is fast-growing (high grade) but at an early stage. For example, a tumour in your brain can be fast-growing, but may be at an early stage. This means the cancer hasn’t spread, but the cells look very different to your healthy cells. Therefore, the tumour is fast-growing.
In general, higher grade tumours tend to grow quicker and are more likely to spread, resulting in a higher stage. For more information about the stage and grade of your cancer or what it means, ask your doctor.
How will the stage and grade of cancer affect my chance of recovery?
If you have cancer, your treatment will depend on the type of cancer you have, its stage and its grade. Cancer staging and grading is important because it can help to determine the best way to treat your type of cancer.
If you have a higher grade tumour it’s more likely to spread. A higher stage generally means your cancer is more advanced and has spread. However, this doesn't necessarily mean that your cancer can't be treated or that it will take longer for you to recover. Determining the stage and grade of your cancer will allow your doctor to decide on the most effective treatment for you.
Different treatments are used for different types of cancer. Your doctor will be able to tell you what stage and grade your cancer is and how it may be treated.
I have been told my cancer is recurrent. What does this mean?
Recurrent cancer is when your cancer comes back after treatment.
It’s possible for cancer to come back after treatment – sometimes many years later. This often happens when a small number of cancer cells survive. These cells grow and develop into a new tumour. Recurrent cancer may occur in the same area or in a different part of your body (called secondary cancer). If you have recurrent cancer, you may be given the same treatment as before or a more intensive treatment.
Ask your doctor to explain the chance of your cancer recurring and what you should do if this happens.
It’s not very common, but restaging may be used to measure how your cancer has responded to treatment or to assess if it has come back. Restaging may involve you having some of the tests you had when your cancer was first diagnosed and a new stage may be determined.
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- Types of primary brain tumours. Cancer Research UK. www.cancerresearchuk.org, published 26 November 2013
- Dukes' stages of bowel cancer. Cancer Research UK. www.cancerresearchuk.org, published 13 August 2013
- The stages of a cancer, The cancer cell. Cancer Research UK. www.cancerresearchuk.org, published 24 July 2013
- Treatment for low grade non Hodgkin lymphoma. Cancer Research UK. www.cancerresearchuk.org, published 31 October 2012
- What is cancer? National Cancer Institute. www.cancer.gov, published 2 August 2013
- Cancer staging, Tumor grade. National Cancer Institute. www.cancer.gov, published 3 May 2013
- Sentinel lymph node biopsy. National Cancer Institute. www.cancer.gov, published 11 August 2011
- When cancer returns. National Cancer Institute. www.cancer.gov, published 15 July 2011
- Staging and grading of colon and rectal cancer. Macmillan Cancer Support. www.macmillan.org.uk, published 1 July 2012
- Grading and staging of prostate cancer. Macmillan Cancer Support. www.macmillan.org.uk, published 1 May 2012
- Why do some cancers come back? Macmillan Cancer Support. www.macmillan.org.uk, published 1 October 2011
- Staging. American Cancer Society. www.cancer.org/, published 7 June 2013
- What is cancer staging? American Joint Committee on Cancer. cancerstaging.org, accessed 8 May 2014
- Getting the results. Prostate Cancer UK. prostatecanceruk.org, published February 2014
- Staging colorectal cancer. National Institute for Health and Care Excellence (NICE), 24 March 2014, www.nice.org.uk
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Reviewed by Kuljeet Battoo, Bupa Health Information Team, June 2014.
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