1. What are tumor markers?

Tumor markers are substances that are produced by cancer or by other cells of the body in response to cancer or certain benign (noncancerous) conditions. Most tumor markers are made by normal cells as well as by cancer cells; however, they are produced at much higher levels in cancerous conditions. These substances can be found in the blood, urine, stool, tumor tissue, or other tissues or bodily fluids of some patients with cancer. Most tumor markers are proteins. However, more recently, patterns of gene expression and changes to DNA have also begun to be used as tumor markers. Markers of the latter type are assessed in tumor tissue specifically. Thus far, more than 20 different tumor markers have been characterized and are in clinical use. Some are associated with only one type of cancer, whereas others are associated with two or more cancer types. There is no universal tumor marker that can detect any type of cancer. There are some limitations to the use of tumor markers. Sometimes, noncancerous conditions can cause the levels of certain tumor markers to increase. In addition, not everyone with a particular type of cancer will have a higher level of a tumor marker associated with that cancer. Moreover, tumor markers have not been identified for every type of cancer. 2. How are tumor markers used in cancer care? Tumor markers are used to help detect, diagnose, and manage some types of cancer. Although an elevated level of a tumor marker may suggest the presence of cancer, this alone is not enough to diagnose cancer. Therefore, measurements of tumor markers are usually combined with other tests, such as biopsies, to diagnose cancer. Tumor marker levels may be measured before treatment to help doctors plan the appropriate therapy. In some types of cancer, the level of a tumor marker reflects the stage (extent) of the disease and/or the patients prognosis (likely outcome or course of disease). More information about staging is available in the NCI fact sheet Cancer Staging. Tumor markers may also be measured periodically during cancer therapy. A decrease in the level of a tumor marker or a return to the markers normal level may indicate that the cancer is responding to tr eatment, whereas no change or an increase may indicate that the cancer is not responding. Tumor markers may also be measured after treatment has ended to check for recurrence (the return of cancer).

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3. How are tumor markers measured? A doctor takes a sample of tumor tissue or bodily fluid and sends it to a laboratory, where various methods are used to measure the level of the tumor marker. If the tumor marker is being used to determine whether treatment is working or whether there is arecurrence, the markers level will be measured in multiple samples taken over time. Usually these serial measurements, which show whether the level of a marker is increasing, staying the same, or decreasing, are more meaningful than a single measurement. 4. Does NCI have guidelines for the use of tumor markers? NCI does not have such guidelines. However, some national and international organizations do have guidelines for the use of tumor markers for some types of cancer:
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The American Society of Clinical Oncology (ASCO) has published clinical practice guidelines on a variety of topics, including tumor markers for breast cancer, gastrointestinal cancers, and testicular cancer and extragonadal germ cell tumors in males. These guidelines, called What to Know: ASCOs Guidelines , are available on the ASCO website.

The National Academy of Clinical Biochemistry publishes laboratory medicine practice guidelines, including Use of Tumor Markers in Clinical Practice: Quality Requirements markers for specific cancers. , which focuses on the appropriate use of tumor

5. What tumor markers are currently being used, and for which cancer types? A number of tumor markers are currently being used for a wide range of cancer types. Although most of these can be tested in laboratories that meet standards set by the Clinical Laboratory Improvement Amendments, some cannot be and may therefore be considered experimental. Tumor markers that are currently in common use are listed below. ALK gene rearrangements
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Cancer types: Non-small cell lung cancer and anaplastic large cell lymphoma Tissue analyzed: Tumor How used: To help determine treatment and prognosis
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Alpha-fetoprotein (AFP)
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Cancer types: Liver cancer and germ cell tumors Tissue analyzed: Blood How used: To help diagnose liver cancer and follow response to treatment; to assess stage, prognosis, and response to treatment of germ cell tumors Beta-2-microglobulin (B2M)

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Cancer types: Multiple myeloma, chronic lymphocytic leukemia, and some lymphomas Tissue analyzed: Blood, urine, or cerebrospinal fluid How used: To determine prognosis and follow response to treatment Beta-human chorionic gonadotropin (Beta-hCG)

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Cancer types: Choriocarcinoma and testicular cancer Tissue analyzed: Urine or blood How used: To assess stage, prognosis, and response to treatment BCR-ABL fusion gene

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Cancer type: Chronic myeloid leukemia Tissue analyzed: Blood and/or bone marrow How used: To confirm diagnosis and monitor disease status BRAF mutation V600E

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Cancer types: Cutaneous melanoma and colorectal cancer Tissue analyzed: Tumor How used: To predict response to targeted therapies CA15-3/CA27.29

Cancer type: Breast cancer

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o o

Tissue analyzed: Blood How used: To assess whether treatment is working or disease has recurred CA19-9

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Cancer types: Pancreatic cancer, gallbladder cancer, bile duct cancer, and gastric cancer Tissue analyzed: Blood How used: To assess whether treatment is working CA-125

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Cancer type: Ovarian cancer Tissue analyzed: Blood How used: To help in diagnosis, assessment of response to treatment, and evaluation ofrecurrence Calcitonin

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Cancer type: Medullary thyroid cancer Tissue analyzed: Blood How used: To aid in diagnosis, check whether treatment is working, and assess recurrence Carcinoembryonic antigen (CEA)

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Cancer types: Colorectal cancer and breast cancer Tissue analyzed: Blood How used: To check whether colorectal cancer has spread; to look for breast cancer recurrence and assess response to treatment CD20

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Cancer type: Non-Hodgkin lymphoma Tissue analyzed: Blood How used: To determine whether treatment with a targeted therapy is appropriate
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Chromogranin A (CgA)
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Cancer type: Neuroendocrine tumors Tissue analyzed: Blood How used: To help in diagnosis, assessment of treatment response, and evaluation of recurrence Chromosomes 3, 7, 17, and 9p21

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Cancer type: Bladder cancer Tissue analyzed: Urine How used: To help in monitoring for tumor recurrence Cytokeratin fragments 21-1

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Cancer type: Lung cancer Tissue analyzed: Blood How used: To help in monitoring for recurrence EGFR mutation analysis

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Cancer type: Non-small cell lung cancer Tissue analyzed: Tumor How used: To help determine treatment and prognosis Estrogen receptor (ER)/progesterone receptor (PR)

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Cancer type: Breast cancer Tissue analyzed: Tumor How used: To determine whether treatment with hormonal therapy (such as tamoxifen) is appropriate Fibrin/fibrinogen

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Cancer type: Bladder cancer Tissue analyzed: Urine

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How used: To monitor progression and response to treatment HE4

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Cancer type: Ovarian cancer Tissue analyzed: Blood How used: To assess disease progression and monitor for recurrence HER2/neu

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Cancer types: Breast cancer, gastric cancer, and esophageal cancer Tissue analyzed: Tumor How used: To determine whether treatment with trastuzumab is appropriate Immunoglobulins

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Cancer types: Multiple myeloma and Waldenstrm macroglobulinemia Tissue analyzed: Blood and urine How used: To help diagnose disease, assess response to treatment, and look for recurrence KIT

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Cancer types: Gastrointestinal stromal tumor and mucosal melanoma Tissue analyzed: Tumor How used: To help in diagnosing and determining treatment KRAS mutation analysis

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Cancer types: Colorectal cancer and non-small cell lung cancer Tissue analyzed: Tumor How used: To determine whether treatment with a particular type of targeted therapy is appropriate Lactate dehydrogenase

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o o o

Cancer type: Germ cell tumors Tissue analyzed: Blood How used: To assess stage, prognosis, and response to treatment Nuclear matrix protein 22

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Cancer type: Bladder cancer Tissue analyzed: Urine How used: To monitor response to treatment Prostate-specific antigen (PSA)

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Cancer type: Prostate cancer Tissue analyzed: Blood How used: To help in diagnosis, assess response to treatment, and look for recurrence Thyroglobulin

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Cancer type: Thyroid cancer Tissue analyzed: Tumor How used: To evaluate response to treatment and look for recurrence Urokinase plasminogen activator (uPA) and plasminogen activator inhibitor (PAI-1)

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Cancer type: Breast cancer Tissue analyzed: Tumor How used: To determine aggressiveness of cancer and guide treatment 5-Protein signature (Ova1)

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Cancer type: Ovarian cancer Tissue analyzed: Blood How used: To pre-operatively assess pelvic mass for suspected ovarian cancer
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21-Gene signature (Oncotype DX)

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Cancer type: Breast cancer Tissue analyzed: Tumor How used: To evaluate risk of recurrence 70-Gene signature (Mammaprint)

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Cancer type: Breast cancer Tissue analyzed: Tumor How used: To evaluate risk of recurrence

6. Can tumor markers be used in cancer screening? Because tumor markers can be used to assess the response of a tumor to treatment and for prognosis, researchers have hoped that they might also be useful in screening tests that aim to detect cancer early, before there are any symptoms. For a screening test to be useful, it should have very high sensitivity (ability to correctly identify people who have the disease) and specificity (ability to correctly identify people who do not have the disease). If a test is highly sensitive, it will identify most people with the diseasethat is, it will result in very few false-negative results. If a test is highly specific, only a small number of people will test positive for the disease who do not have itin other words, it will result in very few false-positive results. Although tumor markers are extremely useful in determining whether a tumor is responding to treatment or assessing whether it has recurred, no tumor marker identified to date is sufficiently sensitive or specific to be used on its own to screen for cancer. For example, the prostate-specific antigen (PSA) test, which measures the level of PSA in the blood, is often used to screen men for prostate cancer. However, an increased PSA level can be caused by benign prostate conditions as well as by prostate cancer, and most men with an elevated PSA level do not have prostate cancer. Initial results from two large randomizedcontrolled trials, the NCI-conducted Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, or PLCO, and the European Randomized Study of Screening for Prostate Cancer, showed that PSA testing at best leads to only a small reduction in the number of prostate cancer deaths. Moreover, it is not clear whether the benefits of PSA screening outweigh the harms of follow-up diagnostic tests and treatments for cancers that in many cases would never have threatened a mans life.
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Similarly, results from the PLCO trial showed that CA-125, a tumor marker that is sometimes elevated in the blood of women with ovarian cancer but can also be elevated in women with benign conditions, is not sufficiently sensitive or specific to be used together with transvaginal ultrasound to screen for ovarian cancer in women at average risk of the disease. An analysis of 28 potential markers for ovarian cancer in blood from women who later went on to develop ovarian cancer found that none of these markers performed even as well as CA-125 at detecting the disease in women at average risk. 7. What kind of research is under way to develop more accurate tumor markers? Cancer researchers are turning to proteomics (the study of protein structure, function, and patterns of expression) in hopes of developing new biomarkers that can be used to identify disease in its early stages, to predict the effectiveness of treatment, or to predict the chance of cancer recurrence after treatment has ended. Scientists are also evaluating patterns of gene expression for their ability to help determine a patients prognosis or response to therapy. For example, the NCI-sponsored TAILORx trialassigned women with lymph nodenegative, hormone receptorpositive breast cancer who have undergone surgery to different treatments based on their recurrence scores in the Oncotype DX test. One of the goals of the trial is to determine whether women whose score indicates that they have an intermediate risk of recurrence will benefit from the addition of chemotherapy to hormonal therapy or whether such women can safely avoid chemotherapy. The trial has accrued its required number of subjects and these subjects will be followed for several years before results are available. NCIs Early Detection Research Network is developing and testing a number of genomic- and proteomic-based biomarkers. The Program for the Assessment of Clinical Cancer Tests (PACCT), an initiative of the Cancer Diagnosis Program of NCIs Division of Cancer Diagnosis and Treatment, has been developed to ensure that development of the next generation of laboratory tests is efficient and effective. The PACCT strategy group, which includes scientists from academia, industry, and NCI, is developing criteria for assessing which markers are ready for further development. PACCT also aims to improve access to human specimens, make standardized reagents and control materials, and support validation studies. A new program, the Clinical Assay Development Program, allows NCI to assist in the development of promising assays that may predict which treatment may be better or that will help indicate a particular cancers aggressiveness.

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1. What is staging? Staging describes the severity of a persons cancer based on t he extent of the original (primary) tumor and whether or not cancer has spread in the body. Staging is important for several reasons:

Staging helps the doctor plan the appropriate treatment. The stage can be used to estimate the persons prognosis. Knowing the stage is important in identifying clinical trials that may be suitable for a particular patient. Staging helps health care providers and researchers exchange information about patients; it also gives them a common terminology for evaluating the results of clinical trials and comparing the results of different trials. Staging is based on knowledge of the way cancer progresses. Cancer cells grow and divide without control or order, and they do not die when they should. As a result, they often form a mass of tissue called a tumor. As the tumor grows, it can invade nearby tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream or the lymphatic system. By moving through the bloodstream or lymphatic system, cancer cells can spread from the primary site to lymph nodes or to other organs, where they may form new tumors. The spread of cancer is called metastasis.

2. What are the common elements of staging systems? Staging systems for cancer have evolved over time. They continue to change as scientists learn more about cancer. Some staging systems cover many types of cancer; others focus on a particular type. The common elements considered in most staging systems are as follows:

Site of the primary tumor. Tumor size and number of tumors. Lymph node involvement (spread of cancer into lymph nodes). Cell type and tumor grade* (how closely the cancer cells resemble normal tissue cells). The presence or absence of metastasis. *Information about tumor grade is available in the National Cancer Institute (NCI) fact sheetTumor Grade: Questions and Answers, which can be found athttp://www.cancer.gov/cancertopics/factsheet/Detection/tumorgrade on the Internet.
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3. What is the TNM system? The TNM system is one of the most widely used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). Most medical facilities use the TNM system as their main method for cancer reporting. PDQ, NCIs comprehensive cancer information database, also uses the TNM system. The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes(N), and the presence of distant metastasis (M). A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread. Primary Tumor (T) TX T0 Tis Primary tumor cannot be evaluated No evidence of primary tumor Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called preinvasive cancer) T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N) NX N0 N1, N2, N3 Regional lymph nodes cannot be evaluated No regional lymph node involvement

Involvement of regional lymph nodes (number of lymph nodes and/or extent spread)

Distant Metastasis (M) MX M0 M1

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Distant metastasis cannot be evaluated No distant metastasis Distant metastasis is present

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For example, breast cancer classified as T3 N2 M0 refers to a large tumor that has spread outside the breast to nearby lymph nodes but not to other parts of the body. Prostate cancer T2 N0 M0 means that the tumor is located only in the prostate and has not spread to the lymph nodes or any other part of the body. For many cancers, TNM combinations correspond to one of five stages. Criteria for stages differ for different types of cancer. For example, bladder cancer T3 N0 M0 is stage III, whereas colon cancer T3 N0 M0 is stage II. Stage Stage 0 Stage I, Stage Definition Carcinoma in situ. Higher numbers indicate more extensive disease: Larger tumor size and/or spread of the cancer beyond

II, and Stage III the organ in which it first developed to nearby lymph nodes and/or organs adjacent to the location of the primary tumor. Stage IV The cancer has spread to another organ(s).

Question 6 describes sources of additional information about staging for specific types of cancer. 4. Are all cancers staged with TNM classifications? Most types of cancer have TNM designations, but some do not. For example, cancers of the brain and spinal cord are staged according to their cell type and grade. Different staging systems are also used for many cancers of the blood or bone marrow, such as lymphomas. TheAnn Arbor staging classification is commonly used to stage lymphomas and has been adopted by both the AJCC and the UICC. However, other cancers of the blood or bone marrow, including most types of leukemia, do not have a clear-cut staging system. Another staging system, developed by the International Federation of Gynecology and Obstetrics, is used to stage cancers of the cervix, uterus, ovary, vagina, and vulva. This system uses the TNM format. Additionally, childhood cancers are staged using either the TNM system or the staging criteria of the Childrens Oncology Group, which conducts pediatric clinical trials. Many cancer registries, such as NCIs Surveillance, Epidemiology, and End Results Program (SEER), use summary staging. This system is used for all types of cancer. It groups cancer cases into five main categories:

In situ: Abnormal cells are present only in the layer of cells in which they developed. Localized: Cancer is limited to the organ in which it began, without evidence of spread.

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Regional: Cancer has spread beyond the primary site to nearby lymph nodes or organs and tissues. Distant: Cancer has spread from the primary site to distant organs or distant lymph nodes. Unknown: There is not enough information to determine the stage.

5. What types of tests are used to determine stage? The types of tests used for staging depend on the type of cancer. Tests include the following:

Physical exams are used to gather information about the cancer. The doctor examines the body by looking, feeling, and listening for anything unusual. The physical exam may show the location and size of the tumor(s) and the spread of the cancer to the lymph nodes and/or to other organs.

Imaging studies produce pictures of areas inside the body. These studies are important tools in determining stage. Procedures such as x-rays, computed tomography (CT) scans,magnetic resonance imaging (MRI) scans, and positron emission tomography (PET) scanscan show the location of the cancer, the size of the tumor, and whether the cancer has spread.

Laboratory tests are studies of blood, urine, other fluids, and tissues taken from the body. For example, tests for liver function and tumor markers (substances sometimes found in increased amounts if cancer is present) can provide information about the cancer.

Pathology reports may include information about the size of the tumor, the growth of the tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor. Abiopsy may be performed to provide information for the pathology report. Cytology reports also describe findings from the examination of cells in body fluids.

Surgical reports tell what is found during surgery. These reports describe the size and appearance of the tumor and often include observations about lymph nodes and nearby organs.

6. How can a patient find more information about staging? The doctor most familiar with a patients situation is in the best position to pro vide staging information for that person. For background information, PDQ contains cancer treatment summaries that describe the staging of each type of cancer. PDQ treatment summaries are available at http://www.cancer.gov/cancerinfo/pdq/ on NCIs Web site. Information about cancer staging can also be obtained by calling NCIs Cancer Information Service (CIS) toll -free at 18004CANCER (18004226237). CIS information specialists also offer immediate online assistance through the LiveHelp link at http://www.cancer.gov/ on the Internet.
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Tumor grade is a system used to classify cancer cells in terms of how abnormal they look under a microscope and how quickly the tumor is likely to grow and spread. A pathologist (a doctor who identifies diseases by studying cells under a microscope) determines whether the tumor is benign or malignant. The pathologist also determines the tumor grade. Each type of cancer is graded using a different grading system. Doctors consider tumor grade and other factors when developing an individual treatment plan for a patient. 1. What is a tumor? In order to understand tumor grade, it is helpful to know how tumors form. The body is made up of many types of cells. Normally, cells grow and divide to produce new cells in a controlled and orderly manner. Sometimes, however, new cells continue to be produced when they are not needed. As a result, a mass of extra tissue called a tumor may develop. A tumor can be benign (not cancerous) or malignant (cancerous). Cells in malignant tumors are abnormal and divide without control or order. These cancerous cells can invade and damage nearby tissue, and spread to other parts of the body (metastasize). 2. What is tumor grade? Tumor grade is a system used to classify cancer cells in terms of how abnormal they look under a microscope and how quickly the tumor is likely to grow and spread. Many factors are considered when determining tumor grade, including the structure and growth pattern of the cells. The specific factors used to determine tumor grade vary with each type of cancer. Histologic grade, also called differentiation, refers to how much the tumor cells resemble normal cells of the same tissue type. Nuclear grade refers to the size and shape of the nucleus in tumor cells and the percentage of tumor cells that are dividing. Tumor grade should not be confused with the stage of a cancer. Cancer stage refers to the extent or severity of the cancer, based on factors such as the location of the primary tumor, tumor size, number of tumors, and lymph node involvement (spread of cancer into lymph nodes). (More information about staging is available in the National Cancer Institute fact sheet Cancer Staging.)

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3. How is tumor grade determined? If a tumor is suspected to be malignant, a doctor removes a sample of tissue or the entire tumor in a procedure called a biopsy. A pathologist (a doctor who identifies diseases by studying cells under a microscope) examines the tissue to determine whether the tumor is benign or malignant. The pathologist can also determine the tumor grade and identify other characteristics of the tumor cells. 4. What do the different tumor grades signify? Based on the microscopic appearance of cancer cells, pathologists commonly describe tumor grade by four degrees of severity: Grades 1, 2, 3, and 4. The cells of Grade 1 tumors resemble normal cells, and tend to grow and multiply slowly. Grade 1 tumors are generally considered the least aggressive in behavior. Conversely, the cells of Grade 3 or Grade 4 tumors do not look like normal cells of the same type. Grade 3 and 4 tumors tend to grow rapidly and spread faster than tumors with a lower grade. The American Joint Committee on Cancer recommends the following guidelines for grading tumors (1): Grade GX G1 G2 G3 G4 Grade cannot be assessed (Undetermined grade) Well-differentiated (Low grade) Moderately differentiated (Intermediate grade) Poorly differentiated (High grade) Undifferentiated (High grade)

5. Does the same grading scale apply to all tumors? Grading systems are different for each type of cancer. For example, pathologists use the Gleason system to describe the degree of differentiation of prostate cancer cells. The Gleason system uses scores ranging from Grade 2 to Grade 10. Lower Gleason scores describe well-differentiated, less aggressive tumors. Higher scores

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describe poorly differentiated, more aggressive tumors. Other grading systems include the Bloom-Richardson system for breastcancer and the Fuhrman system for kidney cancer. 6. Does tumor grade affect a patients treatment options? Doctors use tumor grade and many other factors, such as cancer stage, to develop an individual treatment plan for the patient and to predict the patients prognosis. Generally, a lower grade indicates a better prognosis (the likely outcome or course of a disease; the chance of recovery or recurrence). However, the importance of tumor grade in planning treatment and estimating a patients prognosis is greater for certain types of cancers, such as soft tissue sarcoma, primary brain tumors, lymphomas, and breast and prostate cancer. Patients should speak with their doctor about tumor grade and how it relates to their diagnosis and treatment. Selected References 1. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002. Understanding Cancer Prognosis

Key Points A prognosis is an estimate of the likely course and outcome of a disease. Many factors affect the prognosis of a person with cancer, including the type, location, and stage of the cancer. When estimating a patients prognosis, doctors usually use statistics based on data from groups of people whose situations are most similar to that of the patient. Doctors cannot estimate with certainty what the outcome will be for an individual cancer patient. 1. What is a prognosis? A prognosis is an estimate of the likely course and outcome of a disease. The prognosis of a patient diagnosed with cancer is often viewed as the chance that the disease will be treated successfully and that the patient will recover. 2. What factors affect a patients prognosis? Many factors can influence the prognosis of a person with cancer. Among the most important are the type and location of the cancer, the stage of the disease (the extent to which the cancer has spread in the body), and the cancers grade (how abnormal the cancer cells look under a microscopean indicator of how quickly the cancer is likely to grow and spread).
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Other factors that affect prognosis include the biological and genetic properties of the cancer cells (these properties, which are sometimes called biomarkers, can be determined by specific lab and imaging tests), the patients age and overall general health, and the extent to which the patient s cancer responds to treatment. 3. How do statistics contribute to predicting a patients prognosis? In estimating a cancer patients prognosis, doctors consider the characteristics of the patients disease, the available treatment options, and any health problems the patient may have that could affect the course of the disease or its ability to be treated successfully. The doctor bases the prognosis, in large part, on information researchers have collected over many years about hundreds or even thousands of people with the same type of cancer. When possible, doctors use statistics based on groups of people whose situations are most similar to that of the patient. Several types of statistics may be used to estimate a cancer patients prognosis. The most commonl y used statistics are listed below.
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Cancer-specific survival: This statistic calculates the percentage of patients with a specific type and stage of cancer who have survivedthat is, not died fromtheir cancer during a certain period of time (1 year, 2 years, 5 years, etc.) after diagnosis. Cancer-specific survival is also called disease-specific survival. In most cases, cancerspecific survival is based on causes of death in medical records, which may not be accurate. To avoid this inaccuracy, another method used to estimate cancer-specific survival that does not rely on information about the cause of death is relative survival.

Relative survival: This statistic compares the survival of patients diagnosed with cancer (for example, breast cancer) with the survival of people in the general population who are the same age, race, and sex and who have not been diagnosed with that cancer. It is the percentage of cancer patients who have survived for a certain period of time after diagnosis relative to people without cancer.

Overall survival: This statistic is the percentage of patients with a specific type and stage of cancer who are still alivethat is, have not died from any causeduring a certain period of time after diagnosis.

Disease-free survival: This statistic is the percentage of patients who have no evidence of cancer during a certain period of time after treatment. Other similar terms are recurrence-free or progression-free survival. Cancer survival statistics are frequently given in terms of 5-year survival relative to the general population (that is, as 5-year relative survival percentages or rates). For example, according to NCIs Surveillance, Epidemiology,
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and End Results program, the 5-year relative survival rate for all women diagnosed with breast cancer during the period from 2001 through 2007 was 89 percent and the 5-year relative survival rate for all patients diagnosed with lung cancer during the same period was 16 percent. Because survival statistics are based on large groups of people, they cannot be used to predict exactly what will happen to an individual patient. No two patients are entirely alike, and their treatment and responses to treatment can vary greatly. Also, because it takes years to see the impact of new treatments and diagnostic tests, the statistics a doctor uses to make a prognosis may not reflect the effectiveness of current treatments. Nevertheless, the doctor may speak of a favorable prognosis if the information from large groups of people suggests that the cancer is likely to respond well to treatment. A prognosis may be unfavorable if the cancer is likely to be difficult to control. It is important to keep in mind, however, that a prognosis is only an estimate. Again, doctors cannot be absolutely certain about the outcome for an individual patient. 4. Is it helpful to know the prognosis? Cancer patients and their loved ones face many unknowns. Understanding their disease and what to expect can help patients and their loved ones make decisions about treatment, supportive and palliative care, rehabilitation, and personal matters, such as financial matters. Seeking information about prognosis is a personal decision. Many people with cancer want to know their prognosis. They find it easier to cope when they know the likely course of their disease. Some patients may ask their doctor about survival statistics or search for this information on their own. Other people find statistical information confusing and frightening, and they think it is too impersonal to be of value to them. It is up to each patient to decide how much information he or she wants. A doctor who is most familiar with a patients situation is in the best position to discuss his or her prognosis and explain what the statistics may mean. 5. What is the prognosis if a patient decides not to have treatment? Because everyones situation is different (see Question 2), this question can be difficult to answer. Also, information used in making a prognosis often comes from studies that have compared new treatments with existing treatments rather than with no treatment. Therefore, it is not always easy for doctors to accurately estimate the prognosis of a patient who decides not to have treatment. However, as mentioned above (see Question 4), a doctor who is most familiar with a patients situation is in the best position to discuss his or he r prognosis.
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There are many reasons why patients may decide not to have treatment. Some patients may be concerned that the benefits of cancer treatments will be outweighed by the side effects. Patients should discuss this concern with their doctor or other health care provider. Many medications are available to prevent or control the side effects caused by cancer treatments. Some patients may decide at some point not to have treatment if they know that their type andstage of cancer has a poor prognosis, despite treatment. Patients who choose not to have active cancer treatment should talk with their doctor to ensure that they get palliative treatment to help with the symptoms caused by their disease. In these cases, patients may want to think about clinical trials. Clinical trials are research studies that involve people. They test new ways to prevent, detect, diagnose, or treat diseases. People who take part in cancer clinical trials have an opportunity to contribute to scientists knowledge about cancer and to help in th e development of improved cancer therapies. They also receive state-of-the-art care from cancer experts. People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from NCIs Cancer Information Service at 18004CANCER (18004226237) and in the NCI booklet Taking Part in Cancer Treatment Research Studies. This booklet describes how research studies are carried out and explains their possible benefits and risks. Additional information about clinical trials is available on NCI's Clinical Trials page. This page contains a link to NCIs clinical trials search form, which can be used to find clinical trials that are currently accepting patients. 6. What is the difference between a cure and a remission? A cure means that treatment has successfully eradicated all traces of a pers ons cancer, and the cancer will never recur (return). A cure does not mean, however, that the person will never have cancer again. It is possible that another cancer, even the same type of cancer, will develop in the persons body at some point in the fut ure. A remission means that the signs and symptoms of a persons cancer are reduced. Remissions can be partial or complete. In a complete remission, all signs and symptoms of cancer have disappeared. If a patient remains in complete remission for 5 years or more, some doctors may say that the patient is cured. However, some cancer cells can remain undetected in a persons body for years o r even decades after apparently successful treatment, and these cells may eventually cause a recurrence. Although most types of cancer usually recur within the first 5 years after diagnosis and treatment, later recurrences always remain a possibility.

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Therefore, doctors cannot say with any certainty that an individual cancer patient is cured. The most they can say is that there are no signs of cancer at this time. Because of the possibility of recurrence, doctors continue to monitor patients for many years and do tests to look for signs of cancers return. They will also look for signs of delayed adverse effects from the cancer treatments received.

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LOGBOOK BOD SK 7/CITRA MUTIAH SARI/1206207810/PBL-3