August 18, 2011

Take the stage

Staging cancers can be a confusing science. You need to know three things: how much the tumour has grown (T), how many lymph nodes are involved (N), and whether the cancer has metastasized (M) or spread. Different values for these three factors combine to give you an overall stage (Stage 1, 2, 3 or 4).

TNM system

Someone could have a high T but a low N, and the person sitting next to them with the ‘same’ cancer in the ‘same’ spot may have a low T and a high N. These numbers matter because they are good predictors of how long someone sits on the Endangered Species List, or even if they will one day come off the list at all.

There are two types of staging: clinical and pathological.

My clinical stage: T4 + N1? + M0 = Possible Stage 3 colorectal cancer

When clinically staging colorectal cancers doctors use evidence collected via biopsy and CT, PET and MRI images. My clinical stage was uncertain because some scans showed that a lymph node may have been cancerous, but the images weren't crystal clear. My tumour was clearly the highest level possible (T4) because it could be seen on the images trying to eat other organs outside the bowel.

Clinical staging is imperfect because of limitations in medical imaging. This round of staging is quite important though because it determines whether you have chemo or radio or chemoradiotherapy before surgery (and how much).

A second round of staging takes place once the tumour has been sighted during surgery, removed and analysed by a pathologist.

My pathological stage: T2 + N0 + M0 = A good result, but…

While in hospital I didn't ask about my pathology results because I was being hammered by the leak, dehydration and infection and wasn't ready for additional stress. The doctor, knowing the results were positive, decided to unleash them on me after a few weeks:
  • The entire tumour was removed, cancer-free tissue on all sides
  • The tumour was downgraded from T4 to T2
  • Zero lymph nodes were cancerous

    Up down, good bad, win loss
    This result is good, but it is unclear how good. The chemoradiotherapy (and all my other healing strategies) did a good job of making the tumour smaller (at the time of surgery no tumour was outside the bowel wall) and wiping out that ? node. But, my tumour was once a T4 and there was once a ? node. Only if the pre-surgical therapies had completely killed the tumour or made it vanish would my course of treatment change.

    The fact remains: While the surgical result was good (I got to keep my bladder and some vital man-organs after all), and the tumour is gone, I still had a nasty cancer when I first walked into the hospital and that is what will guide my next phase of care.

    The next step

    I’m told that chemotherapy needs to start within 12 weeks of surgery or it doesn’t work so well at helping you get off the Endangered Species List. I’m told that my cancer is ‘high risk’ for either coming back in the same area or in another organ. I’m told the clock is ticking and we need to move soon, leaking colon or no leaking colon.


    1. Keep up the good work, Ben. Why did the tumor get downgraded to T2 from T4? --michelle

    2. Hey Michelle! Colorectal tumours are measured on a 4 point scale. The levels indicate how far through the bowel wall the tumour has grown. Tumours in the colon start inside the colon and then grow outside the colon. Mine had not only gone outside the colon but had gone even further - making it a 4. After surgery the tests showed that there was no longer tumour outside the colon wall. What was outside the wall was identified as 'fibrosis' (think scar-like connective tissue). Was this fibrosis once tumour? Most likely. Did the chemoradiotherapy and other healing strategies have something to do with this reduction in tumour? Definitely.


    3. Hey Ben, Im glad to hear your chemo radio treatment had a positive result for you before surgery. I finished my six weeks of treatment last friday and expect surgery in five weeks time. I feel like I'm following in your footsteps somewhat. Have you been told how long the follow up chemo will go for? Oh and love ya work on the blogs ;)

    4. Hey Scott, nice to hear from you mate. Yay for finishing chemoradiotherapy. How good does it feel to lose that PICC line?

      I've been to told to expect at least 4 months of adjuvant chemotherapy. It will likely start sometime in the week beginning 6 September.


    5. Yep I was told 4 months also.
      Losing that picc line....Awesome! Not having to visit the hospital everyday for radio... even better!