A number of things must be considered before your doctor can offer you treatment options for your cancer. Your doctor must know how much cancer is in your body, where it is located, whether it has spread and the specific type of cells. In addition, your physician must know how abnormal the cells have become.

The Pathologist

In addition to conducting laboratory tests to diagnose diseases in general, pathologists also conduct specific tests on the cancer to determine a number of factors, including the type of cancer cells, the grade of the cancer, the size of the tumor, the extent the cancer has invaded the surrounding tissue and whether the cancer has spread. This information, compiled in a pathology report, provides you and your medical team critical information to determine the best treatment. 

The pathologist first looks at the tissue with the naked eye in a “gross examination.” Its appearance and characteristics, such as size, weight, color and texture, are recorded. 

If an entire tumor or lesion has been removed, it is microscopically measured from the edge of the mass to the edge of the specimen or “margin.” If cancer cells are found at the edge, it is a “positive” margin, suggesting more cancer cells may remain in the body. A positive margin means more surgery may be needed to ensure removal of all the cancer. A “negative” or clean margin means there are no cancer cells found at the edge of the removed tissue.

Once removed, the specimen is cut into thin slices by the pathologist to be used for further testing. 

The pathologist examines the tissue under a conventional microscope, but there are many techniques that can be used to identify factors involved in the abnormal growth of cells, including fluorescent in situ hybridization (FISH) and immunohistochemistry (IHC). Many of the tumor characteristics identified by these tests can be important factors in choosing the right treatment.

As the technology to examine cells has become more advanced, the pathology offers more extensive information about which treatments will be most effective. 

Ask your doctor about your cancer’s pathology to learn as much as possible about why a certain treatment is recommended and how it will work to fight the cancer. 

If your cancer is very rare, or if your doctor thinks the pathologist’s diagnosis does not seem consistent with your symptoms and other test results, a second opinion might be appropriate.

View Image: FISH and IHC

Grading Systems

The pathologist provides a number of evaluative elements that will help you understand your tumor. Tumor grade, or histologic grade, describes how abnormal the cancer cells appear under the microscope. 

Factors that go into deciding the grade vary but usually include the size and shape of the cell’s nucleus, the proportion of cancer cells that are dividing and the patterns that cells form as they join. If many cells are dividing, it can be a sign the cancer is more aggressive. Cancer cells that look more like normal cells usually grow and multiply slowly and are described as being low grade, well- differentiated or grade 1. Conversely, cancers that do not resemble normal tissues are called high grade, poorly differentiated or grade 3 or 4. The attributes are combined into an overall tumor grade that ranges from 1 to 4 depending on the type of cancer. 

Ask your doctor what factors go into grading your tumor and the scale used. For example, the grading system for prostate cancer ranges from 2 to 10. 

No matter the system used, lower numbers signify less aggressive cancers, while higher numbers indicate more rapid growth. Tumor grade is an important indicator of prognosis in some cancers, such as breast, prostate, brain, lymphoma and soft-tissue sarcoma.

View Illustration: How Big Is My Tumor?

Staging Systems

Your cancer will also be staged from 0 to 4 with 4 usually indicating the cancer is advanced. Cancers are staged differently so try to understand how your cancer was staged and how important it is for your cancer type. 

Staging for most cancers is based on the following:

> Location and size of the primary tumor;
> How many tumors are present and whether the cancer has spread to nearby organs and tissues, including the lymph nodes; and
> Whether the cancer has spread (metastasized) to distant organs and/or tissues. 

For some cancers, such as bone and soft-tissue sarcoma, the grade is taken into consideration when the cancer is staged. In addition to the pathology report, information used for staging is gathered from physical examinations and imaging tests, such as X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans.

View Chart: Typical TNM Tumor Staging System

View Chart: Overall Stage Groupings

TNM staging uses three characteristics of the cancer. The T refers to the primary tumor (the place where the cancer began); the N refers to the level, if any, of lymph node involvement; and the M refers to the presence or absence of metastasis. The meaning of these letters and numbers may vary for different types of cancer; some cancers may not have N3 as a category, and in other cancers, the classifications may have subcategories, such as T3a or T3b. Ask your physician about the staging system for your cancer. 

Once these factors have been determined, an overall number is assigned. If you are treated and then experience a recurrence, your cancer may or may not be restaged. A restaged cancer often is indicated by inclusion of the letter “R.”

Newer chromosomal tests and the analysis of multiple genes at a time (also known as gene profiling) may subclassify your cancer and help determine your treatment. 

No matter the factors used to stage your cancer, try to understand why your physician is recommending a particular treatment. Be an active participant in your care.  

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