Treatments by Type of Cancer

• Breast Cancer
• Childhood Cancer
• Colon and Rectal
• Leukemias and Multiple Myeloma
• Lung Cancer
• Lymphomas
• Metastatic Disease
• Skin Cancer

Link to download: Breast Cancer Treatment Chart 

Cancers in children can be treated with chemotherapy, surgery, radiation therapy, immunotherapy, or bone-marrow transplantation, depending on the type, stage, and location of the cancer (see Various Types Of Cancer Treatment)

More than 60 percent of childhood cancers are treated in clinical trials, that is, research studies comparing available treatments with new treatments that might be more effective.

In general, most childhood cancers grow fast and respond well to chemotherapy. Chemotherapy drugs are delivered directly to the bloodstream to target cancer cells throughout the body. Different types of cancer require different types or combinations of chemotherapy drugs.

Surgery is done to remove cancerous tumors. Surgeons try to remove the entire tumor and a small amount of healthy tissue around the tumor, called the margin, to make sure no cancer is left behind.

Radiation therapy is used to kill cancer cells with high-energy x-rays or other cancer-destroying particles. External beam radiation targets cancer cells from outside the body with a special machine. Internal radiation therapy, or brachytherapy, uses radioactive material sealed in needles, seeds, wires, or catheters and placed in or near a tumor inside the body to destroy cancer cells.

Immunotherapy uses substances produced by the body or created in a lab to stimulate or restore the ability of the body’s immune system, its natural defense system against infections and some cancers, to fight your child’s cancer.

Bone-marrow transplantation involves first destroying a child’s leukemia in the bone marrow with high doses of chemotherapy or radiation therapy and then infusing healthy bone marrow or blood stem cells into the child’s veins to replace the destroyed bone marrow. The new marrow may come from a donor, such as a brother or sister or other relatives, or it may consist of the child’s own marrow or blood stem cells that have been treated to destroy any cancer cells.

Children diagnosed with cancer require a team of pediatric oncology physicians and specialists, including pediatric surgical oncologists, radiation oncologists, pediatric medical oncologists or hematologists, pediatric nurse specialists, rehabilitation specialists, and physical therapists. Treatment may also involve other professionals, such as psychologists, nutritionists, social workers, child life specialists, and educators.

You can find teams of childhood cancer specialists at children’s hospitals and pediatric cancer centers (see Understanding Cancer Treatment Facilities).

Link to download:  Colon Cancer Treatment Chart

The most common types of gynecologic cancer are:

• Uterine Cancer
• Cervical Cancer
• Ovarian Cancer
   

Uterine Cancer

This cancer is the most frequent gynecologic cancer.

Endometrial Cancer, also called adenocarcinoma, begins in the endometrium, the lining of the uterus. Endometrial cancer accounts for about 95 percent of uterine cancers. While it mostly affects postmenopausal women, 25 percent of cases are seen in premenopausal women, with 5 percent of these under age 40.

After diagnosis, you may be referred to a gynecologic oncologist, a doctor who’s had specialty training in both the surgical and the chemotherapeutic management of gynecologic cancers. Your doctor will surgically remove the uterus and cervix (a simple hysterectomy) or those organs plus the upper part of the vagina and nearby tissues (a radical hysterectomy). The doctor also may take out nearby lymph nodes, as well as the fallopian tubes and ovaries.

Your doctor will inspect the removed organs to stage your cancer — that is, to determine the extent to which the disease has spread. Since surgery removes the tumor, it not only helps determine the stage of the disease but also may be curative.

Your doctor may use a staging method known as the FIGO (International Federation of Gynecology and Obstetrics) system. Although subdivisions exist, in simple terms, cancer confined to the uterus is stage I; cancer with cervical involvement is stage II; cancer with local spread outside the uterus is stage III; and cancer with spread to the bladder, rectum or further is stage IV. Most patients have stage I and II uterine cancers, which have the highest survival rates.

Your doctor also may determine the tumor’s grade after examining tumor cells under a microscope. If the cells appear similar to normal tissue, the tumor is considered low-grade. If they don’t look like normal tissue, the tumor is high-grade. Low-grade tumors usually grow more slowly than high-grade tumors, which are more likely to spread.

Knowing your tumor’s stage and grade helps your doctor decide whether to recommend further treatment after surgery. Options for further treatment include radiation therapy, hormone therapy and chemotherapy, alone or in combination. Your doctor may use these therapies without surgery if your tumor can’t be removed or if health problems prevent surgery. In some cases, radiation therapy shrinks the tumor before surgery. 

Cervical Cancer

This type of cancer develops in the cervix, the lower part of the uterus that connects the uterus to the vagina. This cancer is most commonly found in women of reproductive age. The most important risk factor for cervical cancer is infection with the sexually transmitted human papillomavirus.

The two main kinds of cervical cancer are:

• Squamous Cell Carcinoma. About 80 to 90 percent of cervical cancers are squamous cell carcinomas, which arise from the squamous cells that cover the cervix.
• Adenocarcinoma. This less common type of cervical cancer develops in the glandular cells lining the cervical canal. Between 10 and 20 percent of cervical cancers are this type.

The treatment for cervical cancer depends on the stage. Stage I disease is limited to the cervix and is most often treated by radical hysterectomy and removal of the lymph nodes. (The “radical” part of the hysterectomy involves removing more of the tissues that attach to and support the uterus; the cancer is known to spread to these tissues first.)

A fertility-preserving surgery, the radical trachelectomy, takes out the cervix, the top part of the vagina and the pelvic lymph nodes but leaves the rest of the uterus.

Radiation may be used instead of surgery to treat small tumors, or it may be used after surgery for patients at high risk of having the cancer return.

In stage II, the cancer has descended to the upper part of the vagina or reached the tissue around the uterus. In stage III, the cancer is in the lower part of the vagina or the pelvic wall and possibly in the pelvic lymph nodes. In stage IV, the cancer has invaded other body parts.

In general, stages II, III and IV are usually treated with a combination of radiation and chemotherapy. The chemotherapy makes the tumor more sensitive to destruction by the radiation, and it also kills cancer cells outside the radiation field.

Ovarian Cancer

This cancer originates in the ovaries, the two organs attached to the sides of the uterus that produce the eggs and hormones needed for reproduction.

Epithelial Ovarian Cancer is the most common type of ovarian cancer and begins in the epithelial cells on the ovary’s surface. Epithelial cancer constitutes about 85 to 90 percent of ovarian cancers.

Once ovarian cancer is diagnosed, surgery is usually the first treatment. You may be referred to a gynecologic oncologist for care. Research has shown that surgery by gynecologic oncologists results in higher survival rates than surgery by doctors without this type of specialty training, because gynecologic oncologists are more likely to remove all of the cancer at the time of surgery.

Usually the uterus, ovaries, fallopian tubes and nearby lymph nodes are removed for staging. Fatty tissue, called the omentum, in the stomach area, also may be taken out, as well as any fluid in the abdominal area. If the cancer is more extensive, the surgeon may remove it from the intestines, liver and other affected areas. This is called debulking.

Staging also should be performed when a cancerous ovary is removed by a surgeon who was not expecting to find cancer, because a third of these patients are found to have a higher stage than was presumed.

Equally important is having surgery performed before chemotherapy, with the exception of patients whose cancer has spread outside the abdomen or pelvis (such as to the liver, brain or lung) or patients who are too high a risk for surgery because of heart, lung or other severe medical conditions. In those cases, chemotherapy may be the first treatment.

Disease limited to one or both ovaries is stage I, local spread to organs in the pelvis is stage II, spread to the abdominal lining or lymph nodes is stage III and distant spread is stage IV. The doctor also may determine the tumor’s grade, which indicates how abnormal the cells are.

After surgery, staging and grading, your doctor may recommend intravenous chemotherapy, most commonly in the form of a two-drug combination, although single agent and oral regimens are sometimes used. A newer chemotherapy technique, intraperitoneal chemotherapy, involves injecting the drugs into the abdominal cavity.

Radiation is rarely used for primary treatment. It is most commonly used to treat some recurrences.

Women who are diagnosed with ovarian cancer should know about an inherited condition known as familial breast-ovarian cancer syndrome. This common syndrome is responsible for 10 percent

 of ovarian cancers and 5 to 10 percent of all breast cancers. Women with one of these cancers face increased risk of developing the other.

Hematologic cancers are cancers of the blood or blood-forming tissues, such as bone marrow. Leukemia, lymphoma and multiple myeloma are the general types of hematologic cancers.

These cancers develop as a result of genetic errors in immature blood cells, known as stem cells. The stem cells reproduce themselves over and over again, leading to an overabundance of these abnormal blood cells, which are cancer cells that never mature, continue to proliferate uncontrollably and enter the bloodstream.

Within the past decade, physicians have made enormous progress in the treatment of hematologic cancers with new drugs, resulting in saved and prolonged lives and significantly improved quality of life for patients.

Leukemias

Acute lymphoblastic (or lymphocytic) leukemia (ALL) is a cancer arising in bone marrow. In people with ALL, abnormal stem cells develop into lymphoblasts or lymphocytes (white blood cells that fight infection) that are not able to fight infection well. As these cells increase in numbers in bone marrow and blood, they may cause anemia, infection and easy bleeding, and they may spread to the brain and spinal cord.

Chronic lymphocytic leukemia develops when the abnormal lymphocytes in bone marrow and lymph nodes multiply and replace normal lymphocytes over time. This type of leukemia develops slowly, and patients may have no symptoms in the early stages and little change in their health for many years. In time, such symptoms as fatigue, shortness of breath, swollen lymph nodes or spleen and repeated infections may occur.

Acute myeloid leukemia also arises in bone marrow, where abnormal stem cells develop into abnormal myoblasts (immature white blood cells) and sometimes into abnormal red blood cells or platelets (small blood cells). When they build up in bone marrow and blood, they cause the same symptoms as ALL and may also spread to the brain and spinal cord.

Hairy cell leukemia is a type of cancer in which abnormal lymphocytes are present in bone marrow, blood and the spleen. When these cells are looked at under a microscope, they appear to be covered with tiny hairs.

Lymphomas

Hodgkin lymphomas are cancers that arise in the lymphatic system, a part of the body’s immune system made up of lymph vessels, lymph nodes, lymph fluid, the spleen, thymus, tonsils and bone marrow. Symptoms include painless enlargement of lymph nodes, the spleen or other tissues in the immune system, as well as fever, weight loss, fatigue and night sweats. The two major types of these lymphomas are classical Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma.

Nodular lymphocyte-predominant Hodg-kin lymphoma is a less common type of Hodgkin lymphoma, making up about 5 percent of all Hodgkin lymphomas. It is distinct from the other types, which are collectively called classical Hodgkin lymphomas and are classified into four subtypes based on the type of cells found in the patient’s lymph nodes, including nodular sclerosing subtype, mixed cellularity subtype, lymphocyte-rich subtype and lymphocyte-depleted subtype.

Non-Hodgkin lymphomas are a complex group of cancers also arising in the lymph system. These lymphomas are often marked by enlarged lymph nodes, fever and weight loss. Non-Hodgkin lymphomas may be aggressive or slow growing and classified as either B-cell or T-cell (types of lymphocytes) lymphomas. In addition to arising in lymph nodes, B-cell and T-cells lymphomas may also develop in other places in the body, such as the nasal sinuses.

The various types of B-cell non-Hodgkin lymphomas include Burkitt lymphoma, diffuse large B-cell lymphoma, small lymphocytic lymphoma, follicular lymphoma, precursor B-lymphoblastic lymphoma, MALT (mucosa-associated lymphoid tissue) lymphoma, lymphoplasmacytic lymphoma, nodal marginal zone lymphoma, splenic marginal zone lymphoma and mantle-cell lymphoma.

The various types of T-cell non-Hodgkin lymphomas include:

• adult T-cell lymphoma/leukemia
• mycosis fungoides
• anaplastic large-cell lymphoma
• cutaneous T-cell lymphoma
• precursor
• T-lymphoblastic lymphoma
• lymphoblastic
• lymphoma
• peripheral T-cell lymphoma
• angioimmunoblastic lymphoma
• angiocentric lymphoma (nasal T-cell lymphoma)
• intestinal T-cell lymphoma
• Sézary syndrome

Multiple Myelomas

Multiple myeloma is cancer that arises in plasma cells (white blood cells that produce antibodies to fight bacteria and viruses). Plasma cells are also known as myeloma cells. Multiple myeloma and other plasma-cell cancers develop when abnormal plasma cells are overproduced in bone marrow, preventing bone marrow from producing enough healthy blood cells. In patients with multiple myeloma, the abnormal plasma cells form tumors in many bones of the body.

Multiple myeloma may not cause any symptoms at all, but the symptoms that can develop include bone pain (especially in the back or ribs), bones that break easily, fever, frequent infections, easy bruising or bleeding, difficulty breathing, weakness of the arms or legs and feeling very tired.

Myelodysplastic syndromes are diseases characterized by stem cells that do not mature into healthy red and white blood cells or platelets but remain immature blood cells that do not function normally and die in bone marrow or as they enter the bloodstream. These cancers may cause anemia, infection and easy bleeding.

Additional Sources of Information:

National Cancer Institute: www.cancer.gov/cancertopics/
American Society of Clinical Oncology: www.cancer.net
American Society for Hematology: www.bloodthevitalconnection.org/for-patients/blood-cancers/
The Leukemia and Lymphoma Society: www.leukemia-lymphoma.org

Research has shown that the combination of chemotherapy and radiation therapy (often referred to as chemoradiation therapy), with or without surgery, provides the best outcomes for most individuals with stage III non-small cell lung cancer. The combination of chemotherapy and radiation therapy is also the most commonly used treatment for limited stage small cell lung cancer. Chemotherapy with supportive care is given for stage IV non-small cell cancer or extensive stage small cell lung cancer. 

Several chemotherapy drugs have been shown to kill lung cancer cells (Table 1). For initial treatment (first-line treatment), a two-drug combination is typically used, and one of the drugs is usually a platinum drug (cisplatin or carboplatin). Chemotherapy is given in cycles, or a series of treatments for several days. Each cycle (usually 21 days) is followed by a rest period to allow the individual’s body to recover from the effects of the drugs. The number of cycles given depends on the type and stage of the cancer — but is usually four to six cycles for lung cancer. If the cancer does not respond during treatment or progresses, different chemotherapy drugs may be used as second-line treatment. There are many clinical trials adding a new drug to these regimens. For patients with epidermal growth-factor receptor gene (EGFR) mutations, erlotinib or gefitinib (pills) may be superior (see Targeted Therapy below).
 

Targeted Therapy

The latest advance in the treatment of nonsmall-cell lung cancer is targeted therapy. Targeted therapy involves the use of drugs or biologic substances that attack lung cancer cells specifically without harming normal cells. Three targeted therapy drugs have been approved for the treatment of advanced non-small cell lung cancer or lung cancer that has progressed during treatment (Table 2). These drugs may be given alone or in combination with chemotherapy. Targeted therapy is most often used for individuals with advanced non-small cell lung cancer and/or individuals who have nonsmall-cell lung cancer that has not responded to one or two combinations of traditional chemotherapy drugs. Targeted therapy is not effective for small cell lung cancer. Recent data show that an oral pill (erlotinib or gefitinib) is superior to multi-agent intravenous chemotherapy as initial treatment for stage IV lung cancer patients whose tumors have EGFR mutations.

Websites with information on targeted therapy drugs are listed here:

• www.immunotherapyforcancer.info
• http://chemoregimen.com/Lung-Cancer
• www.cancer.gov/drugdictionary
• www.fda.gov/Drugs/default.htm

Surgery

Surgery offers the best chance for cure of early stage non-small cell lung cancer (stage I or II). Surgery may be done to remove a small part of the lung where the tumor is located. This is known as wedge resection. Depending on the size and location of the tumor — and the overall health of the lungs — it may be preferable to remove a lobe of the lung containing the tumor (known as lobectomy) or, less often, the entire lung (pneumonectomy). Nearby lymph nodes must be removed during any of these operations. A pathologist will examine the lymph nodes to determine if they contain cancer cells. It is important to know whether there are cancer cells in the lymph nodes, as more aggressive treatment is needed to kill cancer that has spread beyond the lung.  Surgery is sometimes done as part of treatment of stage III non-small cell lung cancer but it is rarely done for stage IV disease. Surgery is sometimes done for limited stage small cell lung cancer.

Surgery to remove all or part of a lung is done with the patient under general anesthesia. Individuals who have no other lung disease (such as chronic bronchitis or emphysema) can usually gradually resume normal activities after the operation. However, individuals who have another lung disease may need to limit activity or wear oxygen tubes because of shortness of breath after the surgery.

Video-assisted thoracic surgery (VATS) is a new approach that is less invasive than traditional lung cancer surgery. It has been evaluated in patients who have stage I or II disease. The procedure enables the surgeon to make much smaller incisions than those used for open surgery, which means the length of time needed for recovery is shorter. VATS may be beneficial for older or frail individuals or those who are unable to tolerate major surgery.

Table 1. Chemotherapy Drugs for Lung Cancer

Table 2. Targeted Therapy for Non-Small Cell Lung Cancer

Once cancer metastasizes, the goal of treatment is to manage the cancer by slowing or reducing its growth, even though it may be unlikely to completely eliminate every cancer cell. Chemotherapy and/or radiation therapy may be given to help keep the cancer from progressing further. When possible, surgery may be done to remove one or a few metastatic tumors to help relieve symptoms or to prevent them later on. A new approach to treating metastatic disease is called targeted therapy. This type of treatment involves the use of biologic substances that specifically attack the development of cancer cells. (See Understanding Targeted Treatment). Depending on the type of cancer, it is possible to live for many years after metastatic cancer is diagnosed if tumor growth can be managed. A clinical trial offers the best opportunity for a person to be treated for metastatic cancer.
 

Liver cancers are malignant tumors that begin in various parts of the liver. The liver is the largest organ in the body and is found behind the ribs on the right side of the abdomen. The liver performs several vital functions to keep the body healthy. It processes and stores many of the nutrients absorbed from the intestine and secretes bile into the intestine to help the body digest fat from food. The liver also plays an important part in removing toxic substances from the blood.

Cancer that begins in the liver is called primary liver cancer. Although primary liver cancer is the fifth most common cancer around the world, it is much less common in the United States. However, it is common for cancer to spread to the liver from the colon, lungs, breasts, or other parts of the body. When this happens, the disease is not called liver cancer. The cancer in the liver is a secondary cancer. It is named for the organ or the tissue where it began, such as metastatic colon cancer which spread to the liver (see Understanding Metastatic Cancer, page 18).

The types of liver cancers are named for the different types of cells where they begin. These cancers have different causes, are treated differently, and have a different outlook for recovery.

Most primary liver cancers begin in the main type of liver cells, called hepatocytes. This type of cancer is called hepatocellular carcinoma or malignant hepatoma. About 75 percent of primary liver cancers are of this type. In the United States, this type of cancer usually begins in many locations throughout the liver. It can also begin as a single tumor that grows larger and then spreads throughout the liver. Children can also have primary liver cancers. These include hepatocellular carcinoma or hepatoblastoma, a rare cancer that usually affects children younger than four. Treatment for children with liver cancer is different than treatment for adults.

About 10 percent to 20 percent of primary liver cancers arising from the ducts draining bile into the small intestine. Such tumors are called cholangiocarcinomas. These cancers start in the small bile ducts (tubes in the liver that carry bile to the gallbladder) or in the main common bile duct just beneath the liver. Cholangiocarcinomas are often treated the same way as hepatocellular carcinomas. A small number of liver cancers are angiosarcomas and hemangiosarcomas. These are rare cancers that begin in the blood vessels of the liver

Liver cancer is sometimes called a silent disease because in early stages, it often does not cause symptoms. As the cancer grows, symptoms may include pain in the upper abdomen on the right side, possibly extending to the back and shoulder; swollen or bloated abdomen; weight loss; loss of appetite and feelings of fullness; weakness or tiredness; nausea and vomiting; yellow skin and eyes, and dark urine from jaundice; and fever.

Patients newly diagnosed with liver cancer are referred to specialists for treatment. Specialists who treat liver cancer include surgeons (especially those who specialize in liver surgery), gastroenterologists, medical oncologists, and radiation oncologists (see Finding Doctors Who Specialize In Treating Your Type Of Cancer, page 22).

Additional Sources of Information:

• American Liver Foundation: www.liverfoundation.org
• American Cancer Society: www.cancer.org
• CancerCare, Inc.: www.cancercare.org

With the widespread use of prostate-specific antigen (PSA) testing to identify men at increased risk of prostate cancer, more individuals have been diagnosed with prostate cancer than in the period before PSA testing was widely available (pre-1992). Cancers diagnosed through PSA testing are often early stage or less advanced cancers. According to data from the National Cancer Institute, more than 90 percent of all prostate cancers are now diagnosed at a less advanced stage and men are surviving longer after diagnosis and treatment.

Once prostate cancer is diagnosed, you and your doctor must go through a process of risk assessment, estimating the likelihood that your cancer has or may spread outside the prostate and assessing your risk of disease recurrence after treatment. This assessment combined with characteristics of your overall health will allow your doctor to advise which treatment option will benefit you the most. Your doctor will use factors such as your Gleason score (see Staging Prostate Cancer, page 73), PSA level, tumor stage and the number of tumor samples (called cores) taken by biopsy that are positive for cancer.

A variety of factors and tools can be used to assess your chances of surviving prostate cancer and the effectiveness of treatment in halting the progression of the disease. Among the tools your doctor may use are Internet-based calculators or nomograms, published tables and biological markers that may help predict outcomes.

Calculators or Nomograms

Online prostate cancer calculators, also called nomograms, provide forecasts of prostate cancer outcomes by calculating the statistical probability of disease progression or patient survival after treatment by comparing your individual information to data from many hundreds or thousands of other prostate cancer patients. Two particularly comprehensive calculators are available on Web sites from Memorial Sloan Kettering Cancer Center in New York (www.nomograms.org) and the University of Montreal (www.nomogram.org) .

The advantage of these predictive tools is that they are individualized to your particular condition and characteristics. The calculators ask you to respond to questions about your PSA level, age, tumor stage, Gleason score, biopsy cores and planned treatment or other information. Calculators are available to help you and your physician make treatment decisions before and after initial treatment and after a relapse.

However, as more men are diagnosed with lower-risk disease, these nomograms are proving less useful. For those men with newly diagnosed prostate cancer the great majority will be assessed as low or intermediate risk. These nomograms provide limited information to distinguish those men whose cancers will be cured from those in whom treatment will fail. In men with low or intermediate risk disease, new approaches and technologies involving biological markers are being developed to improve your doctor’s ability to estimate the curability of the cancer (see Biological Markers below).

You should talk with your physician or medical team to help you interpret the results of these calculators and make decisions about any planned treatment. The statistics you receive by filling out these nomograms will help you have an informed discussion with your doctor.

Partin Tables

Created in 1997 and updated in 2001, Partin tables are published tables developed by urologists at the Brady Institute for Urology at Johns Hopkins University in Baltimore. Named for the lead authors of this research, the Partin tables are based on data from patients treated at three major prostate cancer research institutions: Johns Hopkins, Baylor College of Medicine in Houston and the Michigan Prostate Institute at the University of Michigan in Ann Arbor.

Like the online calculators, the Partin tables combine data on PSA levels, Gleason score and tumor stage to predict specific treatment outcomes for an individual patient. Physicians can use the tables to calculate probability estimates of four different risk factors that are important in making treatment decisions:

• that your cancer is completely confined to the prostate;
• that you have capsular penetration, meaning that your prostate cancer has extended into and possibly through the capsule (hard outer covering) of the prostate;
• that your cancer has extended into the seminal vesicles (glands behind the prostate);
• that your prostate cancer has spread to the lymph nodes.

It’s important to understand that the value of these tables in predicting outcomes has never actually been proved, and you should discuss the value of these tables with your physician.

Biological Markers

PSA is a widely used biological marker, or biomarker, of prostate cancer risk. A lot of research is currently being done to identify other biomarkers of risk that may enhance the predictive value of nomograms and improve a physician’s ability to predict capsular penetration and distant metastasis (spread) of prostate cancer as well as cancer recurrence after treatment.

New approaches to risk assessment for prostate cancer are also emerging that combine biomarker testing, biopsy tissue analysis and clinical data to provide personalized risk assessments that could improve the accuracy of predicting patient outcomes from cancer treatments.

Prostate Cancer Staging

Once prostate cancer has been diagnosed, it is important to find out whether or not the cancer has grown beyond the prostate. Doctors rely on the findings of imaging studies to determine the stage of disease, or how extensive the cancer has become. A widely used system helps doctors classify the stage of cancer according to such characteristics as the size and location of the tumor and the absence or presence of cancer in nearby lymph nodes or other parts of the body. This system was developed by the American Joint Committee on Cancer and is known as the tumor, node, metastasis (or TNM) classification. The stage of the prostate cancer, along with prostate-specific antigen (PSA) levels, is an important factor in planning treatment. In addition, the doctor uses the staging information to help predict the prognosis, or outcome, which also aids in selecting a treatment approach that is best for an individual man with prostate cancer.

As a first step in determining the stage of prostate cancer, the doctor who has evaluated the findings of diagnostic tests will assign a clinical stage (Table 1). This stage will be confirmed or modified by the pathologist who examines tissue removed during surgery (the pathological stage). The pathologist will also grade the tumor according to how it looks under a microscope. The grade assigned to the tumor is known as the Gleason score. The Gleason score ranges from 2 to 10; a low score is given when the tumor cells are similar to the normal cells in the prostate tissue. Higher scores are given for greater differences between the tumor cells and the normal cells. The more different the tumor cells are from normal, the more likely the tumor is to spread. Gleason scores are grouped as follows:

As the last step in determining the overall stage, the TNM classifications and the Gleason score are considered together to classify prostate cancer as stage I, II, III, or IV (Table 2). Some doctors may use an older staging system, the Whitmore-Jewett system, and assign stage A, B, C or D to the prostate cancer. Patients are encouraged to ask their doctors to explain the staging system they use or to translate the stage into a stage determined by the TNM and Gleason classifications

Table 1. TNM Classification of Prostate Cancer

*When a tumor is found during surgery not related to prostate cancer, it is further classified as T1a if tumor cells are found in 5% or less of the surgically removed prostate tissue, and as T1b if tumor cells are found in more than 5% of the surgically removed prostate tissue. A tumor is classified as T1c if it is found during a needle biopsy, usually done because of an elevated prostate-specific antigen (PSA) level.

Table 2. Stages of Prostate Cancer

The treatment of skin cancers depends on whether the lesion is a nonmelanoma or a melanoma. Several treatment options are available for nonmelanomas, and the choice depends on many factors, such as the location and characteristics of the tumor (size, depth, and location); the individual’s age, general health condition, and personal preference; and the potential cosmetic result.

Generally, this can be accomplished by excision of the skin cancer with a small margin of the surrounding skin. The surgeon and the pathologist will generally verify that the skin cancer is generally removed with a “quick stain” during the operative procedure. If there is still residual tumor, then more skin must be excised. For melanomas, surgical treatment involves a wider excision of skin surrounding the melanoma in an amount that varies according to tumor thickness. The goals are to remove all cancerous tissue and to minimize the likelihood that the cancer will recur (grow back). Surgical excision is usually the preferred treatment for both types of skin cancer.

In addition to surgical excision of a melanoma, dissection (removal) of lymph nodes that contain cancer cells may also necessary. Surgery is the most effective treatment in this circumstance. If a melanoma is thick or has spread to one or more lymph nodes, the physician may recommend adjuvant therapy after the surgery, which is treatment given after the primary treatment.

The goal of adjuvant therapy is to kill cancer cells that are not yet detectable, and this treatment increases the likelihood that the melanoma will not recur. Adjuvant therapy may include biological therapy (also called immunotherapy) or radiation therapy or both. At present, there is no documented benefit of chemotherapy after surgery. When melanoma is metastatic at the time it is diagnosed, a combination of surgery and radiation therapy may be recommended to eliminate the primary melanoma as well as control the metastatic disease.

Surgical Excision and Lymph Node Dissection

Surgical excision involves removal of the melanoma and a small amount of normal tissue around the lesion (known as the surgical margin). The normal tissue is removed to make sure that all cancer cells have been eliminated. This procedure is known as a wide local excision. How wide the excision should be is determined by how thick the tumor is, but it is generally recommended at either a half-inch or an inch of skin surrounding the melanoma. After the lesion has been removed, the margins of the wound are sewn together. 

If sentinel node biopsy was done previously and showed that melanoma had spread, the lymph nodes in the area of the sentinel node may have to be dissected. Sentinel lymph node mapping and biopsy may be done at the time of removal of the melanoma if the physician finds that the melanoma has adverse features, such as cancer cells in the margins. If this testing indicates that the cancer has spread to the sentinel node, another surgical procedure is performed at a later time to remove additional nearby lymph nodes. If stage III melanoma involving pathologically documented spread of cancer to the lymph nodes is found, lymph node dissection is done during the same procedure as the wide excision.

Sentinal Lymph Node Mapping and Biopsy

One of the most important indicators of survival after treatment of a melanoma is whether it has spread. When melanoma spreads, the first place it is most likely to be found is the regional lymph node closest to the melanoma. This lymph node is referred to as the sentinel node. A procedure called lymphoscintigraphy, otherwise known as sentinel node mapping, is done to determine the exact drainage of lymph from the skin surrounding the melanoma into the sentinel lymph node. This procedure is usually considered for melanomas that are more than 1 mm thick.

With sentinel node mapping, a small amount of radioactive substance is injected into the skin around the biopsy site of the melanoma and a device that detects radioactivity is used to follow the path of the substance as it travels to the nearest group of lymph nodes. The surgeon will also inject a small amount of blue dye into the skin around the melanoma at the beginning of the operation as a second tracer to precisely identify the sentinel node. The surgeon then makes a small incision in the area of the lymph nodes and removes the sentinel node that has turned blue and/or become radioactive. The surgeon will remove the sentinel node (sentinel node biopsy), and a pathologist will examine it to determine if melanoma cells are present. If no cancer cells are detected in the sentinel node, it is highly unlikely that the melanoma has spread to any lymph nodes.

Sentinel node mapping and biopsy may not be necessary in every case of melanoma, and an individual should discuss this issue with his or her physician.

Chemotherapy and \Immunotherapy

A combination of treatments that may include surgery to remove the melanoma and chemotherapy to treat the metastasis, is needed for stage IV melanoma. Chemotherapy is known as systemic therapy because anticancer drugs travel through the bloodstream to kill cancer cells that have spread beyond the site of the melanoma.

The chemotherapy drugs most commonly used to treat metastatic melanoma include:

• DTIC (dacarbazine) alone
• Combination of DTIC, BCNU (carmustine), and Platinol (cisplatin)
• Combination of DTIC, Platinol, and Velban (vinblastine)Temodar (temozolomide — similar to DTIC but in pill form)

Chemotherapy drugs may be associated with side effects, such as nausea and vomiting, hair loss and mouth sores. These side effects are usually temporary, and treatments are available to help manage them. In addition, chemotherapy can decrease the number of healthy blood cells, which can leave a person feeling tired and weak. A low level of healthy blood cells also makes a person more susceptible to infection or to bruising and bleeding when injured. It is important for individuals to tell their doctor, nurse or other member of the health-care team about side effects so that appropriate treatments can be prescribed to relieve discomfort.

Another treatment option for some melanomas is immunotherapy, or treatment that stimulates the individual’s own immune system to kill cancer cells. The two most commonly used drugs for immunotherapy are interferon-alpha and interleukin-2 (IL-2). These drugs are given in high doses and are most often used for individuals who are participating in a clinical trial.

Immunotherapy may be appropriate if an individual has several melanomas and it is not possible to perform an appropriate wide excision on all of them. Immunotherapy may also be used as adjuvant therapy for melanomas that are thick or have spread to lymph nodes.

Immunotherapy is associated with several side effects, including chills, fever, aches and extreme tiredness. Individuals who are considering immunotherapy should discuss this treatment with their physician to learn about the potential benefits, the likelihood of side effects, and the options for managing these side effects.