Cancer Staging: What It Means and What to Expect

Staging processes for lung cancer have advanced so much over the years that patients are at a lower risk of experiencing a missed cancer diagnosis, according to a presentation during the CURE® Educated Patient® Lung Cancer Summit.

Dr. Thomas Waddington, assistant clinical professor and director of interventional pulmonary medicine at City of Hope in California, discussed the topic of staging in lung cancer during the event. Here, CURE® spoke with Waddington on what resources are available to those patients at a higher risk for lung cancer, advancements in the staging process, what patients can expect and more.

CURE®: What does staging mean for patients?

Waddington: Five years ago until 10 years ago, that’s a much easier answer. What it used to mean was, you do some testing, figure out if it's surgically resectable, not surgically resectable and then what kind of therapy would be offered to you, chemotherapy, radiation therapy. Now, actually, it's not just about defining how extensive the disease is; it's about defining the mutations. And you could argue over 400 different mutations are being evaluated right now. And those mutations are what City of Hope is trying to focus in on and actually just treat those specific mutations. So in other words, if all the cells in your body have X, Y and Z, but only the cancer cells have N, well, you only go after N. And that way you only kill those cells and you minimize the damage to the rest of the body. So as important as anything we used to do, it's not just figuring out how advanced it is. Previous chemotherapy, I kind of call it like napalm. It's just wiping out everything. This is really selective on only trying to hit those specific cells. So the job isn't just to define the stage; it's to get enough tissue to get those samples to define the mutations.

Are there different symptoms that patients can experience depending on the stage they are diagnosed with?

No, that's the worst part. So the lungs don't have any pain receptors. Until you get to a point where there's a sac that surrounds a lung or burrs into other organs, you don't feel it. … Our surface area of our lungs is just under the size of a tennis court. You have thousands of meters of airway, so there's a lot of place to hide. People get a whole lung removed and they breathe just fine. It doesn't hurt. You've got a lot of lung capacity to hide it. The problem with lung cancer — unless you're in a screening program — is it can get so incredibly advanced before you even know it's there. And there's no specific signs or symptoms. And usually when you do have a sign or symptom, it's very advanced.

How has staging advanced?

What we have now, I didn't even have this two years ago. Over the last 20 years, we've developed tools to biopsy literally anywhere in the world with either robots or ultrasounds. Now I can reach places I never reached before. I'm able to diagnose you, stage you and get the tissue we need to help create the treatment you want, and that's really what I do. What I'll be focusing on is how we do that.

The (three) big advancements … in the last 10 to 15 years have been the liquid biopsy. In other words, just drawing blood, looking for gene mutations that way and saying, “Wow, that nodule you have on the CAT scan, that's a really high risk of being cancer. And not only that, it has the certain mutations that we could possibly use X, Y and Z to treat you.”

We have robotic-assisted bronchoscopy right now, that you take a camera half the size of my pinky, you travel through the airways using CAT scans and navigational equipment, and go all the way out to the periphery of the lung, where I just was a couple of days ago and able to biopsy dime-sized lesions now, where that could never have been done two years ago.

One of the biggest tools in the last 15 years were ultrasound devices. Somebody slapped one in the end of a bronchoscope, so now we get to go down through the airways the universe already gave you, look across the walls, now see the tumor or the lymph node and stick a needle no larger than the size of a pin cushion needle into that, get cells, collect it and send it off for analysis.

How do these new methods compare to older ones?

Remember I said there's thousands of meters of airway? The bronchoscopes could only see about two or three (meters). Now, we're literally able to reach out anywhere. You were talking about technology just less than a decade ago that you had maybe a 50/50 shot of finding most nodules sitting anywhere out in the outer two-thirds of the lung, where nowadays it's more like 80% to 90% of the time, we're going to find it. It drops the risk to our patients. Classically, people used to take a needle, stick it across the chest wall under CAT scan guidance to get a hold of nodules and get a hold of the tissue that you needed. Well, the risk of that causing any damage to the lung is about 30%. It wasn't permanent, but for a couple of weeks, it was miserable. Now that risk is cut down to 3%.

What can patients expect from these procedures?

You literally come in, the procedure's done that day, you go home and 90% of the folks tell me the worst part is a sore throat. The other disconcerting part is you cough up blood. I always tell folks, “You're going to cough up blood.” But what I mean by that is you have a white gumball with specks of red, because what ends up happening is these tools I use, the biggest one is the size of a pin, and so imagine me tearing skin — and on your arm, you just put a Band-Aid. You're done. In the airway, you can't do that. So even though you're not bleeding, these little flecks of blood that I can't clear up, you've got to cough them out. That usually takes about a day or two, but it doesn't hurt.

This interview has been edited for clarity and conciseness.

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