How is advanced cancer found?

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 under a microscope. 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 first ask about your medical history (including your symptoms) and give you a physical exam. You may also 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

General signs and symptoms of advanced cancer can include:

• Loss of energy and feeling tired and/or weak: 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.
• Shortness of breath, especially when a cancer has spread to the lungs.

Advanced cancers can also cause many other symptoms, based on the type of cancer and where it is has spread. For more about symptoms, please see the section, "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. For example, results of liver function tests are often abnormal if the cancer has spread to the liver.

Some types of cancer cause substances in the blood called tumor markers to rise. Examples of tumor markers are PSA (prostate-specific antigen) for prostate cancer and CEA (carcinoembryonic antigen) for 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

Imaging tests create pictures of the inside of your body. 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.

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 detailed images of slices of the part of your body being studied.

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 slides 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.

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 doctor moves a biopsy needle through the skin and toward the mass. CT scans are repeated until the needle is within the mass. 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.

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 table that slides inside a long, narrow tube, which is confining and can upset some people. 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 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. A small wand-like instrument gives off sound waves and picks up the echoes as they bounce off the organs. A computer then converts the echoes into a black-and-white image.

Ultrasound is useful for finding out if some tumors are likely to be cancer. This is often an easy test to have done, 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 down the throat or into the rectum or vagina.

PET (positron emission tomography) scans: For a PET scan, a form of sugar that contains low levels of radiation is injected into the blood. Because cancer cells grow quickly, they absorb high amounts of the sugar. You then lie on a table while a special camera detects 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 a different radioactive substance which 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. Problem areas show up as "hot spots," which may suggest cancer, but other bone diseases can also cause hot spots. Other imaging tests or bone biopsies may be needed to learn 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 in some patients, hot spots will not show up in areas of bone that have been totally destroyed by the cancer.

Biopsies and other tests

Often when an imaging test finds something that isn't normal, the doctor will want to be sure that it is cancer. This can often done by taking out a small sample of the abnormal area 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.

Other tests may also be needed. For example, if the doctor thinks the cancer may have spread to the brain or spinal cord (or to the tissues that cover them), a lumbar puncture (spinal tap) may be done. This test is used to look for cancer cells in the cerebrospinal fluid (CSF), which is the liquid that surrounds the brain and spinal cord. For this test, you lie on your side on a bed or exam table with your knees up near your chest. The doctor first numbs an area in the lower back near the spine. A small, hollow needle is then placed between the bones of the spine to withdraw some of the fluid. The fluid is sent to a lab to be looked at under a microscope for cancer cells. Other tests may be done on the fluid as well.