Some cancers are more likely to spread than others. But it is hard to know who will develop metastatic or advanced cancer. One way is to compare how closely the cancer cells look like normal cells (this is called the grade of the cancer). The more normal the cells look, the less likely it is that the cancer will spread. Another way is related to the size of the tumor. A larger tumor is often more likely to have spread. Also, if the cancer is found to have spread to nearby lymph nodes, it is much more likely to have spread to distant sites. This may not be known until after surgery that includes removing lymph nodes to be looked at under the microscope.
Even when these things are known, doctors aren't always sure if a person's cancer will spread or whether they already have advanced cancer. Most of the time, your doctor will look at your history and give you a physical exam. You will have some blood tests and imaging tests. Putting all this information together, your doctor may be able to tell if you have advanced cancer.
Signs and symptoms
Signs and symptoms of advanced cancer can include:
- Loss of energy and feeling tired and/or weak: This may be the most telling symptom. This can get so bad that you may have a hard time doing everyday tasks like bathing or getting dressed. People with advanced cancer often need help with these things. At some point, they may need to spend most of their time in bed. It's important to note that some cancer treatments can cause this symptom, too.
- Weight loss (without trying).
- Pain, such as back pain (for cancer spread to the spine) or abdominal (belly) pain (for cancer spread to the liver).
- Shortness of breath, especially when a cancer has spread to the lungs.
For more about symptoms, please see the section called "Managing symptoms of advanced cancer."
Physical exam
Along with asking about your symptoms, your doctor can learn a lot by examining you. Your doctor may find signs of problems caused by advanced cancer, such as:
- Fluid in your lungs
- Fluid in your belly (abdominal cavity)
- Lumps (tumors) on or within your body
- An enlarged liver
Tests to find advanced cancer
Blood tests
Certain blood tests can point to advanced cancer. Results of liver function tests are often very abnormal if the cancer has spread to the liver. Some types of cancer put out a substance called a tumor marker. Examples are PSA (prostate-specific antigen) if you have prostate cancer, or CEA (carcinoembryonic antigen) if you have colon cancer. The level of these substances in the blood can sometimes be very high in advanced cancer. There are many other tumor markers for other cancers. For more information, see our document, Tumor Markers.
Imaging tests
Many of the tests used to find advanced cancer may have also been done when you were first diagnosed with cancer. You can learn more about these and other imaging tests your doctor may want you to have in our document called Imaging (Radiology) Tests.
Chest x-ray: A chest x-ray can find tumors in your lungs or fluid in your chest.
CT (computed tomography) scan: The CT scan uses x-rays to show a slice or cross-section of your body. The image shows your organs and soft tissues more clearly than standard x-rays. Because the picture is created by a computer, it can be enlarged to make it easier to see details.
Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine takes pictures of many slices of the part of your body that is being studied.
CT scans can also be used to guide a biopsy needle to remove a tissue sample (called a CT-guided biopsy). To do this you stay on the CT scanning table while a radiologist moves a biopsy needle toward the mass. CT scans are repeated until the doctors are sure that the needle is within the area of concern. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is taken out and looked at under a microscope.
CT scans take longer than regular x-rays. You may need to lie still on a narrow table for 15 to 30 minutes while the scan is done. Also, you might feel a bit confined by the large, doughnut-shaped ring that the table moves through while the pictures are being taken. You may hear buzzing and clicking as the scanner switches on and off.
In some cases you may get an IV (intravenous) injection of a contrast agent, or dye, which helps better outline structures in your body. You will need an IV line through which the contrast dye is injected. The injection can cause some flushing. Some people are allergic and get hives. Rarely, people have more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays. You may also be asked to drink 1 to 2 pints of a contrast solution. This helps outline the intestine so that it can be seen clearly.
MRI (magnetic resonance imaging) scan: MRI scans use radio waves and strong magnets instead of x-rays to take pictures of your insides. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. This produces pictures of cross-sectional slices of the body like a CT scanner. A contrast material might be injected just as with CT scans, but this is done less often. MRI scans are very helpful in looking at the brain and spinal cord.
MRI scans take longer than CT scans – often up to an hour, but sometimes even longer. For the test, you lie on a narrow table inside a long, narrow tube, which is confining and can upset people with a fear of enclosed spaces. If you have a strong fear of enclosed areas, ask your doctor if an open MRI (one without an enclosed tube) could be used.
The MRI machine also makes loud buzzing and clicking noises that you may find annoying. Some places give you headphones with music to block this out. Most people don't have any trouble getting an MRI, but you should feel free to talk to your doctor or nurse about any concerns you have. You will be able to talk to the technician the whole time you are getting an MRI.
Ultrasound: Ultrasound uses echoes from sound waves to make pictures of a body part. The computer shows the pictures on a screen. Ultrasound is useful for finding out if some tumors are likely to be cancer. This is often an easy test to take, and it uses no x-rays. In most cases you just lie on a table while a technician moves a flat wand over your skin. In some cases, a special type of wand may be put into the body, such as into the esophagus, rectum, or vagina.
PET (positron emission tomography) scans: For a PET scan, a form of sugar (glucose) that contains low levels of radiation is injected into the blood. Because cancer cells grow quickly, they absorb high amounts of the sugar. A special camera can then detect the radioactivity. PET is useful when your doctor thinks the cancer may have spread but doesn't know where. PET scans can be used instead of many different x-rays because it scans your whole body at one time. PET scans can give useful information, but they aren't very detailed. Special machines can combine PET and CT scans (PET/CT scanners) to give more detailed pictures.
Bone scan: This test can help show if cancer has spread to your bones. It is a lot like a PET scan, but it uses an IV injection of a radioactive substance that is more likely to collect in problem areas in the bones. A special camera picks up the radiation and a computer turns it into pictures of the skeleton, including the problem "hot spots." These areas may suggest cancer is present, but arthritis, infection, or other bone diseases can also cause hot spots. Other imaging tests or bone biopsies may be needed to know just what is causing the hot spots seen on the scan.
Bone scans can find cancer spread much earlier than regular x-rays. They can also be used to track how these areas respond to treatments. But sometimes bone scans do not find areas of spread to the bones. In some patients, hot spots will not show up in areas of bone that have been totally destroyed by the cancer.
Biopsy
Often when an imaging test finds something that isn't normal, the doctor will want to be sure that it is cancer. This is done by taking a small piece of tissue and looking at it under the microscope. This is called a biopsy. Usually a thin, hollow needle is put into the spot and fluid, bits of tissue, or a core of tissue is pulled out. It is important that your doctor knows whether the cancer has spread, and often a biopsy is the only way to know for sure.
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