Ask Us Anything About… The Stages of Cancer

Description – The video begins inside the Penn State Cancer Institute. Two people are standing next to each other looking at the camera. From left to right is, Dr. Joseph Drabick  and Scott Gilbert.

Scott Gilbert – From Penn State Health, this is Ask Us Anything About; the stages of cancer. I’m Scott Gilbert. So a lot of people seem to put stock in the stage of cancer, whether it’s zero, one, two, three or four with which they or their loved one has been diagnosed, but many may not realize what those different stages mean or even how stage one, or two, or one type of cancer may be curable but not so much for another type. Here to answer some questions about this, it’s Dr. Joseph Drabick, he’s Division Chief for Hematology and Oncology here at Penn State Cancer Institute. Dr. Drabick, thank you for making the time. I appreciate it.

Dr. Joseph Drabick  – No problem, yeah, no problem.

Scott Gilbert – Let’s start by talking about what the stages designed to tell us about someone’s cancer, perhaps just as importantly tell the care team physicians.

Dr. Joseph Drabick  – OK. So the staging system is a very useful tool that’s been developed. And the staging system is specific for each kind of cancer. So you can’t talk about a stage two breast cancer being equivalent to a stage two pancreatic cancer. They’re apples and oranges, you don’t compare the two. But the stage within a cancer tells the prognosis of the patient for– in general for that and it’s based on statistics on large groups of individuals with a certain characteristic of their tumor and where it has spread to regionally and it tells what kind– is kind of the tea leaves generally of what’s going to happen. But even they have their issues or not a 100% and it’s based on large populations but are very useful, the most common staging system for most solid tumors like breast, pancreatic, liver type of cancers, would be what they call the TNM system, T-N-M, as the T tell us characteristics about the primary tumor, what is like, how deep it is, how big it is, some of the characteristics of it and tells the– if the disease has spread to the local regional lymph nodes that drain that particular area. And then M, stands for distomatosis, it doesn’t spread beyond that. So when you’re talking about stage four, you’re generally talking about individuals who actually have metastasis already which should be an M1, an M positive, so the more the disease have spread.

Scott Gilbert – So it sounds like the numeric system, the TNM system, they’re not separate or just one or the other, they kind of interrelate.

Dr. Joseph Drabick  – They interrelate. And so– and it varies from tumor to tumor, a certainty, a certain anus, a certain animal manifest those being at certain stage. For example, having metastasis for certain cancer is isn’t a death sentence. For example, you’ve got testicular cancer, you could have metastasis to certain organs and still be cured off of your disease. And actually in that situation, they actually have a different staging system is actually staged three includes metastasis, so it’s a little bit nuance but it’s just– it’s important to realize that every tumor has its own uniqueness and you can’t just compare this tumor to that tumor as apples and oranges because it doesn’t work.

Scott Gilbert – Sure. You’re watching Ask Us Anything About; the stages of cancer from Penn State Health, I’m Scott Gilbert alongside Dr. Joseph Drabick. He’s Chief of Hematology and Oncology here at Penn State Cancer Institute, which is where are today. And we welcome your questions and your comments. So feel free to add those in the comment field below this Facebook post. We’ll post those questions to Dr. Drabick whether you’re watching this video live here on Monday or if you’re watching that for the fact, we’ll still get your answers to those questions. You know, so let’s briefly walk through those numeric stages and what each mean? We often think of stages one, two, three and four but before that, there’s actually a stage zero. I feel like that we don’t hear about this very often.

Dr. Joseph Drabick  – Yes, yeah. So for some cancers, there is a stage zero, not all. But it’s important to realize because it has implications. So stage zero generally means it’s in situ which means in place in land. So– And a good example of that, a common in situ cancer is ductal carcinoma in situ or DCIS in breast cancer. Basically, the tubules– the ducts of the breast have cancer in them, but the cancer cells haven’t figure a way to go beyond the edge of the tubules, they’re still stuck in the tubules. So it’s still– we would treat that, we would treat that with surgery and to remove it, but it doesn’t have the metastatic potential like a stage one or the disease has already figured out how to go across the tubular boundary. Another example is melanoma in situ, so you can have a melanoma of your skin, at stage zero. So it hasn’t figured a way to start eating down into the skin yet, it’s all in the superficial layer and you just cut it out and generally that’s the end of that.

Scott Gilbert – And so, you talked a little bit about stage one, let’s take the next step, stage two, what does that mean as compared to stage one?

Dr. Joseph Drabick  – Well, it varies for tumor to tumor. So– But generally, it means that the tumor is getting larger or the regional lymph nodes are involved. And it depends on the particular situation of lung cancer, breast cancer. You can’t stay like a stage two is the same TNM as a stage two for a different cancer. Each one is unique, we had whole books, which I’ll show you, that go over this, so it’s not just–

Scott Gilbert – Wow.

Dr. Joseph Drabick  – a straightforward thing and basically you have to look at the anatomy, so this shows you the various T stages and this shows you the various N stages and it comes up for the overall stage grouping. But basically the stage grouping kind of tells you the prognosis of the patient like the survival over time. And so, for patients with certain high risk disease, you would want to perhaps interdict to try and prevent a recurrence and [inaudible] of the disease. And actually, for an oncologist, that’s a lot of bread and butter, we don’t treat actual tumors that have been seen, we treat potentiality, micrometastasis that may or may not be at their basal stage to try and prevent if those micromass are out there and the higher stage would suggest if there’s a good better chance of them being there that we would do something to try and prevent that from coming back.

Scott Gilbert – That’s why– you touched a little bit on stage three then and also– we also hear those at stage four. That’s that– That’s not the language that nobody wants to hear with regards to their cancer.

Dr. Joseph Drabick  – Yeah. So for many tumors, when you have a stage four, it means that the disease has already spread beyond the confines of the just the regional area and has spread to far away targets, other organs for example. But it’s not a 100% fail, as I mentioned you can have metastasis and still be cured for certain cancers. A good example is lymphomas. So the lymphomas are hematologic cancer but we still use a staging system for them according to their spread pattern. So a stage four diffuse large B-cell lymphoma which is a form of non-Hodgkin lymphoma. You can still cure even though the disease is far spread to them. And we would treat it with chemotherapy.

Scott Gilbert – You’re watching Ask Us Anything About; the stages of cancer from Penn State Health. I’m Scott Gilbert alongside Dr. Joseph Drabick, he’s the Region Chief for Hematology and Oncology here at Penn State Health. And we welcome your questions for him. Cancer touches all of us, so we’re pretty sure that you probably have a question for him that he could handle today. And Denise is the first off with the question about thyroid cancer. She’s asking, if someone had thyroid cancer and the doctors removed everything, is it possible to get cancer again?

Dr. Joseph Drabick  – Well, that’s a very good question. So that’s the whole point of why things are done to try to prevent that in certain situations based on risk. And thyroid cancer would be applicable as well, as well as the more chronic cancers like breast and colon. So basically what– the problem with cancer is that it can send off little cells to your bloodstream or through you lymphatics and they could be invisible, so at that time that the surgery is done, the surgeons says like, I don’t know, there’s no other disease, and sure enough from their perspective, yes, they’ve got it all. But the problem is there could be these little cells that are floating and stuck out there and many years could come back and haunt you. So it’s possible with the thyroid cancer that can still come back. Hopefully not and hopefully things we’re going to try and decrease the likelihood of that. For example, for high risk thyroid cancer, sometimes, we’ll give radioactive iodine that kill those little cells that might be out there. And actually using the radioactive iodine sometimes, they could see them as very– actually they can see it as well as kill it. So sometimes, we’ll do that. If the risk is not deemed too high then they would not– you would not do that and its likelihood that that would happen that you’d get distant recurrence would be small enough that is– that you’ve for all intents and purposes you can do well over time.

Scott Gilbert – When we talk about cancer staging, we’re talking about not just solid tumors but also cancers of the blood, right?

Dr. Joseph Drabick  – Right, right. So for some cancers on blood like acute leukemia for example, the stage existing doesn’t really apply and just– it’s just the whole bone marrows involved with acute leukemia. And we have other factors that we’ve taken to the account for prognosis, so a lot of them are based on molecular task, so certain forms of leukemia. If you have this certain molecular anomaly one good example is [inaudible] three then you’re more likely of your occurrence of death and you’d probably want to do something beyond what you usually do to keep them in remission. And actually now, we know that there are actually agents, so we can use to target this particular molecular anomalies. And those molecular tests are actually finding their way into solid tumor realm too. So for example, it’s well-known that you could have a stage one cancer and it still come back and haunt you. So there are tests being developed to try and add to the staging or fine-tune so to speak with these molecular features, the biology of the tumor that will tell more about what does prognosis is going to be.

Scott Gilbert – Sounds good. Next question comes from Natalie. She’s asking, is it true that cancer can’t live in a ketogenic body? Can you explain what that means?

Dr. Joseph Drabick  – Well, it turns out that if, you know, the metabolism– there’s different modes of metabolism and ketogenic is basically where you’re not having regular glycolysis or glucose formation. It’s not a 100% correct but there’s some animal data suggest that if you’re in a ketogenic state, it kind of store ups the tumor a little bit. It’s still in the animal model sort of realm but there are some suggestion that’s true. That certain– there are certain mutations of tumors that they thrive more on pure sugars glucose rather than that. If you keep them in an environment where they’re forced, you know, taking that away that those cancers may grow more slowing.

Scott Gilbert – When we talked a lot about staging, zero through four, what about pre-cancerous growth?

Dr. Joseph Drabick  – Right.

Scott Gilbert – So for example with colorectal cancer, that can be called a pre-cancerous stage in the form of polyps.

Dr. Joseph Drabick  – Right.

Scott Gilbert – Do those get in number as well or is that before the staging system kicks in?

Dr. Joseph Drabick  – Right. So that’s before the number in general. So– But basically, yeah, so you have pre-cancerous lesions that can give rise to cancerous lesion. So the idea is that you would remove them before they’re– that’s the whole benefit of doing a screening colonoscopy for colorectal cancer. And everyone over 60 and then in certain high risk groups you do it more frequently because the idea is you can catch them early, remove them and not only does– diagnose them, it actually therapeutically removes them so you decrease the likelihood of recurrence and death. And this has been shown to be effective in that manner.

Scott Gilbert – You’re watching Ask Us Anything About the Stages of Cancer from Penn State Health. I’m Scott Gilbert. This is Dr. Joseph Drabrick. And we welcome your questions for him. We’ve had some great one so far. So please do keep them coming here whether you’re watching this video live or after the fact. One question from Chris, Chris is asking, if someone had stage one breast cancer and had a lobectomy and radiation treatment but shows not to take tamoxifen, what are the percentages of cancer reoccurring?

Dr. Joseph Drabick  – Why–

Scott Gilbert –  It sounds like a very specific–

Dr. Joseph Drabick  – Yeah. I can’t give the exact percentages of that because I don’t treat breast cancer much anymore myself. But basically, the whole idea of tamoxifen is that it turns out a lot of breast cancers or sensitive hormonal manipulation and tamoxifen blocks estrogen which is a certainly growth factor for that. So basically, stage one, two, is a big, it’s not just monolithic, there are different variances with stage one. And also the tamoxifen in addition to preventing recurrence of the disease can prevent new primaries in the other breast. But generally for stage one, hormone receptor positive tumor, the prognosis is generally fairly good. So some people opt not to take that. It’s not a done deal that they’re going to get their recurrence of disease. There are somewhat increased risk compared to someone that didn’t take it, but it’s not like, oh, it’s going to happen for sure. And actually, God forbid, if it does happen, even women with their metastatic recurrence of hormone receptor positive disease, there’s a lot of agents where most of them are pills and not chemo and you can go for many years even with metastatic disease, decades even sometimes.

Scott Gilbert – Now, we talked about the various types of treatment. We generally know it’s chemotherapy, radiation and surgery. And I guess, going to back to something we talked about earlier, it seems like the staging process does kind of help to dictate what the course of treatment will be. But again, that still also depends on the type of cancer–

Dr. Joseph Drabick  – Exactly. Yeah.

Scott Gilbert – it’s not an epidemic way.

Dr. Joseph Drabick  – Right, yes. So every cancer has its own nuances on growing stage. So for example, lung cancer, non-small cell lung cancer for example is a common form of lung cancer. So for an early stage one, you get stage one, you would do surgery. And that would generally be cured. And although there’s still risk of having this micrometastasis coming back to haunt you and for some types of lung cancer, we’ll give chemo afterwards to decrease that likely. But say the lung cancer is locally advanced and has lymph node involvement on the mediastinum which is the central part of your chest, so you really can’t do surgery, but it hasn’t spread anywhere, it’s here so it’s like what do you do for that. And it turns out that you can give concurrent chemotherapy and radiation and cure, a percentage of those patients so that it doesn’t come back, it’s not as good as we would like it for earlier stage disease. But even in those advance stage patients, you can have long-term survival after– and then there’s no surgery involving there at all, it’s just radiation and chemotherapy.

Scott Gilbert – So, you know, we’re going back to the fact that a lot of people put a lot of stock in these numbers in terms of what stage of cancer they’ve been–

Dr. Joseph Drabick  – Yeah, yeah.

Scott Gilbert – diagnosed where did– is it a popular misconception that that number changes depending on whether or not your treatment is successful? So, for example, I had stage three but its gotten better, so now I might be closer to stage one. That’s not really how it works though.

>> No, no. So each– an individual tumor in a patient doesn’t really change stage. This has to do with when you’re diagnosed. So you’re diagnosed say stage two cancer and say God forbid it does come back and has spread to your liver for example [inaudible] stage four, that’s a common misnomer that will– even doctors do, you would say that that’s a metastatic recurrence of the prior stage two. Now, patients can get other cancers totally unrelated to the one they had. I’ve had patients with multiple cancers, so both the same and different type, so you can have, for example, stage two melanoma, this time, it’s taken care off and then they get another melanoma on a different part of their body and now that’s a stage one or they get another one and it’s a stage three. So each of those has its own individual staging associated with it and they don’t change over time, you know. So right now I’m stage four, now I’m stage one, is– it’s whatever it was, the diagnosis.

Scott Gilbert – And not to get too far in the weeds on this, but I think there’s another important distinction too because say someone has lung cancer that, heaven forbid, spreads to the brain, they then do not have brain cancer, rather it’s lung cancer that’s metastatic to the brain. That’s an important distinction, right?

Dr. Joseph Drabick  – Very important. And it’s a common misnomer. People say, all right, grand pop had bone cancer but it really is a prostate cancer that spread to his bones. Because a bone cancer does exist, but it’s much rarer than the cancers that spread through the bone like breast cancer and prostate cancer. Or, as you mentioned lung cancer likes to go to your brain. And it’s not brain cancer because there’s end of– there’s brain cancer has a separate disease. And actually, the staging system for primary brain tumor or likely a blastoma, the TNM system doesn’t really apply in that situation, so.

Scott Gilbert – Yeah. Complex stuff, we get some really good information today. Dr. Joseph Drabick, thanks for your time

Dr. Joseph Drabick  – Thank you.

Scott Gilbert –  I appreciate it.

Dr. Joseph Drabick  – Thank you.

Scott Gilbert – Dr. Drabick is Chief of Hematology and Oncology here at Penn State Cancer Institute. We welcome your questions even if you’re watching this video after the fact and not live. Just add your questions to the comment field and we’ll track down some answers and reply to you. For those of you watching, thanks so much for doing so. And please join us for the next edition of Ask Us Anything About from Penn State Health.