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Stages of cancer


Expert reviewer, Dr Adam Dangoor, Consultant Medical Oncologist
Next review due November 2021

Staging a cancer describes how big your tumour is, whether it has spread and, therefore, how it’s likely to behave in your body. Your doctor may refer to your cancer using a combination of letters and numbers to show the stage it was at when you were diagnosed. This helps your doctor understand more about your cancer and decide on the best way to treat it.



Overview

You may develop cancer if some of your cells grow in an abnormal and uncontrolled way. These then form a tumour. Tumours can be benign (not cancerous) or malignant (cancerous). Sometimes malignant tumours can spread to other parts of your body. This is called secondary cancer, or metastases.

If you’re diagnosed with cancer, your doctor will try to find out:

  • the size of your tumour
  • how far your tumour has spread
  • how quickly your tumour may grow

They will then use the results of their tests to describe your cancer. This is called staging and grading. Staging helps your doctor decide which treatments may be the best ones for you. It also helps your doctor decide how your cancer is likely to behave in your body, and can therefore give you a prognosis (an outlook).

If your cancer is in just one place, your doctor may be able to treat it with surgery or radiotherapy. If your cancer has already spread, you may need to have other treatments that can target cancerous cells in multiple places, such as chemotherapy.

Grading your cancer helps your doctor decide how quickly your cancer may grow and whether it’s likely to spread. This involves looking at your cancer cells under a microscope to see how much they look like normal cells.

About cancer staging

Your doctor may use several tests to work out the stage of your cancer. These tests may include:

  • a CT scan, MRI scan, or a positron emission tomography (PET) scan, which produces detailed images of the inside of your body
  • a blood test to check your blood for certain chemical markers or enzymes
  • a biopsy to identify the type of cancer and its grade

Doctors use two main systems to stage cancer. These are the TNM staging system and the number system (see below). But, depending on the type of cancer you have, your doctor may use other staging systems too. Blood and brain cancers are usually staged differently to other types of cancer. Your doctor may use the Dukes staging system for bowel cancer (see below). It’s important to ask your doctor to explain how they’re staging your cancer and what the letters and numbers mean.

TNM staging system

The TNM system describes:

  • the size of your original (primary) tumour and whether it’s grown into any of your nearby tissues
  • whether any cancer cells have spread from your primary tumour to nearby lymph nodes
  • if cancer has spread to other parts of your body, called metastasis or secondary cancer

This staging helps your doctor to give you a prognosis (outlook). Each stage uses numbers and letters to classify your cancer more specifically. It has also been developed to help doctors study how good various treatments are in clinical trials. Every few years, the TNM staging system is updated in line with data from patients who have been treated for cancer.

T in TNM staging

The 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 assessed.
  • T0 means there’s no evidence of a tumour.
  • Tis or Cis (tumour or cancer in situ) means your tumour is in one small area and hasn’t spread yet. For example, this is often used in staging bladder cancer, when the tumour is still in the inside layer of your bladder lining.
  • T1 to T4 refer to the size of your tumour and how much it has spread. The higher the number, the larger your tumour is, and the more likely it is to have grown into your nearby tissues.

N in TNM staging

The N in the TNM system stands for lymph nodes. Your lymph nodes are part of your immune system. They can be found throughout your body. 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 assessed.
  • 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 where the nodes are in relation to your primary tumour. The higher the number, the more lymph nodes may be affected.

M in TNM staging

The M in the TNM staging system stands for metastasis. This describes whether or not your cancer has spread to other parts of your body.

  • MX may be used if metastasis can’t be measured.
  • M0 means your cancer hasn’t 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.

When your doctor has worked out the T, N and M of your cancer, they’ll combine them to get an overall stage. Your cancer could be T1N1M0, which means it’s only small, and has spread to your lymph nodes but nowhere else in your body.

It’s important to remember that the numbers and letters for each type of cancer don’t mean the same thing. For example, if you have bowel cancer and your TNM is T3N0M0, your cancer will be at stage two. But this combination corresponds to stage three in bladder cancer. So, it can be a bit confusing. If you’re unsure about anything, ask your doctor to explain it.

Sometimes doctors may use smaller letters as well. A stage M1a lung cancer may have spread to your other lung, while a stage M1b or M1c lung cancer has spread to other parts of your body too. If your bowel cancer is T4a, this means it has spread through the lining of the bowel wall. If your bowel cancer is T4b, this means your cancer has stuck to organs or structures next to the bowel.

If there’s a letter p before your cancer stage (such as pT4), this means your doctor has removed your cells during surgery. They have then examined these cells under a microscope (pathology) to stage your cancer.

Number staging system

Your doctor may refer to your cancer stage using numbers. Most types of cancer have four number stages. Your doctor may write down your cancer stage using Roman numerals – so stage 4 cancer may be written as stage IV. For most types of cancer, your doctor may use the following number grades.

  • Stage 1 means your cancer is still quite small and hasn’t spread outside of the organ where it started.
  • Stage 2 means the tumour is larger than in stage 1, but still hasn’t spread anywhere else. With some types of cancer, this may mean the tumour has spread into nearby lymph nodes though.
  • Stage 3 usually means your cancer has grown much bigger and has started to spread. Your doctor may find some cancer in nearby tissues and in your nearby lymph nodes.
  • Stage 4 means your cancer has spread to another organ. This is called secondary or metastatic cancer.

Sometimes doctors will use letters to divide these stages even more. So, your cancer may be a stage 3B cervical cancer.

Dukes staging system

The Dukes staging system is a lettered (A to D) system. It may be used to describe bowel cancer.

  • Dukes A means your tumour has stayed inside the wall of your bowel or has spread slightly into the muscle layer.
  • Dukes B means your tumour has grown through the muscle of your bowel wall.
  • Dukes C means your tumour has spread to one or more of your lymph nodes near your bowel.
  • Dukes D means your original tumour has spread to other parts of your body.

The Dukes staging system is an older system. If your doctor uses it, you may want to ask if they can convert it to the TNM staging system. The TNM system provides more information about your cancer.

  • Dukes A is usually T1N0M0 or T2N0M0.
  • Dukes B is usually T3N0M0 or T4N0M0.
  • Dukes C is usually any T, N1, M0 or any T, N2, M0.
  • Dukes D is usually any T, any N and M1.

Cancer grading

If you have cancer, your doctor will use grading to describe what your tumour looks like under a microscope. Your doctor won’t know for sure how your cancer will behave or spread. But grading will give them some idea of how your cancer may progress.

Your doctor will take a sample of cells from your tumour (a biopsy) and send these to a laboratory for testing. A low grade cancer cell looks like a normal cell and is likely to grow more slowly. A high grade cancer cell looks very different from normal cells and is more likely to grow and spread faster.

Cancer is rated with up to four grades. These are described below. 

  • Grade 1 or low grade cancer is slow growing. The cancer cells look a lot like healthy cells in your body.
  • Grade 2 or intermediate grade cancer cells grow slightly faster than normal cells. They look different from healthy cells in your body too.
  • Grade 3, 4 or high grade cancer is fast growing. The cancer cells look very different from healthy cells in your body.

Knowing the grade of your cancer will help your doctor decide on the best treatment for you. They’ll also take into account your stage of cancer, age, general health and anything else that could affect your treatment. If you have a high grade cancer, you may need faster or more intensive treatment than if you have a low grade cancer. Some types of cancer have their own grading systems; for example, prostate cancer uses the Gleason scoring system (described below).

If you’re unsure about how your cancer has been graded or you need more information, ask your doctor.

Gleason scoring system

The Gleason scoring system is used to grade prostate cancer.

Your cancer cells are graded 1 to 5, according to how the cells look under a microscope. Grade 1 cells look like normal prostate cells, and grade 5 cells look very different to normal prostate cells.

Your cancer cells are likely to be a mixture of different grades at any one time. A Gleason score is worked out by adding together the most common grade and the highest grade seen in the remaining cancer cells in your sample. So, if most of your cells are grade 3 and the highest grade in the other cells is grade 4, your total Gleason score will be 7.

Frequently asked questions

  • The stage and grade of your cancer are two different things. You can have a high grade cancer with a low stage, particularly if it has been diagnosed early. For example, an aggressive looking cancer that has not yet spread.

    A slow-growing (low grade) cancer is more likely to be diagnosed at an early (low) stage (before it spreads). However, it can also be diagnosed at an advanced (high) stage (after it has spread). 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 still look very similar to healthy cells. So, the cancer is growing very slowly.

    It’s possible to have cancer that’s growing quickly (high grade) but is still at an early stage, such as in brain cancer. This means the cancer hasn’t spread yet, but the cells look very different to your healthy cells. So, the tumour is growing very quickly.

    Generally, higher grade tumours tend to grow more quickly. This means they’re more likely to spread, which leads to a higher stage. If you have any questions about your own cancer grade and stage, speak to your doctor.

  • If you have cancer, your treatment will depend on the type of cancer you have, its stage and its grade.

    If you have a higher grade tumour, it’s more likely to spread. This is because the cancer cells are growing quickly. A higher stage cancer is generally more advanced and has already spread into your lymph nodes or other organs. But this doesn't necessarily mean your cancer can't be treated or that it will take longer for you to recover.

    Working out the stage and grade of your cancer will mean your doctor can decide on the best treatment for you. It will also give you an idea of your prognosis (outlook) if you want to know.

  • Recurrent cancer is when your cancer comes back after treatment – sometimes years later. This often happens when a small number of cancer cells survive. These cells grow again to form a new tumour. Your cancer may come back 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.

    If your cancer comes back, it may be staged again (called restaging). If your doctor is using the TNM staging system, they may put a small letter r in front of your cancer stage, such as rT3. This shows that your cancer has been restaged.


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Related information

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    • Updated Appendix A: TNM classification of prostate cancer. Royal College of Pathologists. www.rcpath.org, published October 2017
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    • Stages of non-Hodgkin lymphoma. Cancer Research UK. about-cancer.cancerresearchuk.org, last reviewed February 2018
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  • Reviewed by Alice Rossiter, Specialist Health Editor, November 2018
    Expert reviewer, Dr Adam Dangoor, Consultant Medical Oncologist
    Next review due November 2021



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