17 - WHAT IS MEANT BY CANCER STAGE AND HOW IS IT RELATED TO PROGNOSIS?

You cannot leave the starting blocks without learning the type, grade and stage of your particular cancer.  At the outset, everyone may have a notion of what cancer and cancer treatment is, but it is highly unlikely that your concept aligns with your specific type and stage of cancer.

Cancer is a behavioral disease of cells the way crime is a behavioral disorder of humans. Cells which have become cancerous have two aberrant, neigh criminal, behaviors: uncontrolled multiplication and a proclivity to spread to other parts of the body.

 Normal cells respect their neighbors and do not multiply when there is no room or need for repair, whereas cancer cells keep multiplying taking up precious space and taking over the local blood and oxygen supply until neighboring normal cells die or are crowded out. At any point cancer cells may break away to travel in the blood stream or lymph channels (tiny channels like veins that carry lymph fluid instead of blood) to other parts of the body where they settle in like squatters and start multiplying and taking over again. Polite normal breast cells stay in the breast whereas malignant/cancerous ones can travel/metastasize to many other places (most commonly lymph nodes, bones and liver, but also skin and lung but rarely brain) and start making trouble there.

 There are as many types of cancer as there are cell types in the body. The type of cancer is determined by where the cancer started, which organ, not by which organ it has spread to. Location does not change the type. For example, World War II started in Germany and later spread to France, Russia and North Africa. The enemy was always the Nazis.

 Each type occurs in a whole spectrum of grades and stages. Grade is how aggressive the cancer is (Nazi Storm Troopers versus drafted German citizens, to extend the analogy). Stage characterizes the extent of spread of the cancer through the body.

Nazism was a malignant behavior of humans. When Nazism was just growing in Germany, it was like a Stage I cancer. When it spread to Poland it became like a Stage II cancer, which has spread from its primary site to the adjacent lymph nodes. When it spread by air or water to North Africa and Norway it became like the highest stage, a Stage IV cancer, which has spread through the blood stream to the liver, lungs, brain or bone.

 Each type of cancer has a different form of treatment which is modified further according to its grade, stage and possibly genetic or cell surface characteristics.

Advice Regarding Prognosis

Beware of your physician’s prognosis. Or perhaps I should say, beware of what you think the physician is saying about your prognosis. Patients tend to have selective hearing, choosing what they hear, and we as physicians tend to be selective in speaking, carefully choosing specific words. Both tend to excel at giving and receiving good news, but are lousy at giving and receiving grave news. Often times the prognosis is a combination of both good and bad. In which case, it is likely the good will be exaggerated and the bad will be glossed over either in how it is delivered or how you receive it.

It is imperative to listen carefully and ask questions incisively. For the emotionally fragile individual the possibility of any unfavorable side effect can be so frightening that they will be scared away from a therapy with some significant chance of benefit so doctors choose their words careful and don’t exaggerate. Yet a careful explanation of the downside risks is necessary in order for a patients to be prepared should such risks materialize. The conversation is a dance: don’t scare too much but tell just enough to avoid the accusation “you never told me about xyz”.

We are all fragile, and only we, not the doctor, know how much. Physicians are good at managing disease, but you are best at managing your life. Do not assume these are the same, because they aren't. You will need to coax the untold truth about risks out of your doctor. He will be afraid of diminishing the hope that sustains you and thus may inadvertently leave you with a false hope and unprepared. The only way to avoid allowing false hopes to influence your decisions is to not need them. Only unshakable true hopes that are independent of treatment outcome can give you real freedom.  If you have those, your doctor can shoot straight with you and you will hear what he is really saying. Then you can avoid the consequences of misguided hope decisions.