All About Nursing · Hospice & Palliative Care

Determining Prognosis: Patients with Malignant Diseases (Reading & Sharing)

Cancer refers to a group of diseases that are characterized by genetic mutations in normal cells that cause them to become malignant. These genetic mutations involve the following:

      • Oncogenes, which are mutant genes that regulate cell proliferation. Oncogenes allow accelerated proliferation of the mutated cells, resulting in the rapid growth of cancerous tumors. 
      • tumor suppressor genes, which impede cell proliferation and suppress or prevent cell mutations. Cancer involves inactivation of tumor suppressor genes, allowing replication of mutated cells. 

In the TNM system: Cancer patients who require hospice or palliative care generally suffer from advanced disease, which is defined as metastatic spread of the malignancy from the primary site to other areas of the body and/or massive tumor growth at the primary site. The staging of tumors commonly follows the primary tumor, lymph node, and metastasis (TNM) system. 

Primary tumor (T)

  • TX: main tumor cannot be measured
  • T0: main tumor cannot be found
  • T1, T2, T3, T4: refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues. T’s may be further divided to provide more detail, such as T3a and T3b. 

Regional lymph nodes (N)

  • NX: cancer in nearby lymph nodes cannot be measured
  • N0: there is no cancer in nearby lymph nodes
  • N1, N2, N3: refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that contain cancer. 

Distant metastasis (M)

  • MX; Metastasis cannot be measured
  • M0: cancer has not spread to other parts of the body
  • M1: cancer has spread to other parts of the body

Other ways to describe stage:

  • Stage 0: abnormal cells are present but have not spread to nearby tissue. also called carcinoma in situ, or CIS, CIS is not cancer, but it my become cancer.
  • Stage I, II, and III: cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues
  • Stage IV: the cancer has spread to distant parts of the body. 

Determining prognosis: the malignant illness are divided into five categories as follows:

Category I

  • Testicular carcinoma, Choriocarcinoma and trophoblastic malignancy, Childhood acute lymphoblastic leukemia, other pediatric malignancies, acute promyelocytic leukemia, Hodgkin’s disease
  • Cure potential high to moderate even when they present with advanced metastatic diseases (stage IV)
  • End-of-life care indicated when there is disease progression after extensive anti-neoplastic therapy (that will be suffering from advanced metastatic disease that is now resistant to further disease-directed treatment)

Category II

  • Ovarian carcinoma, adult acute myeloblastic leukemia and acute lymphoblastic leukemia, intermediate and high-grade non-Hodgkin’s lymphoma, small cell (oat cell) bronchogenic carcinoma
  • Cure potential low when they present with advanced metastatic diseases (stage IV)
  • Anti-neoplastic therapy in stage IV disease improves quality and length of life.
  • End-of-life care indicated when there is disease progression following first or second-line therapy (depending upon the illness)

Category III

  • Prostate carcinoma, breast carcinoma, chronic lymphocytic leukemia, chronic mylocytic leukemia and the myeloproliferative disorders, low-grade non-Hodgkin’s lymphoma, multiple myeloma and the immunoproliferative disorders, myelodysplastic syndrome, Thyroid carcinoma (except anaplastic)
  • Incurable when they present with advanced metastatic diseases (stage IV)
  • Remission potential high to moderate
  • Indolent course with a long prognosis
  • Anti-neoplastic therapy may be relatively side-effect free (e.g. oral hormonal therapy).
  • End-of-life care indicated when there is evidence of disease progression after one or multiple regimens (depending upon specific disease) of standard anti-neoplastic therapy

Category IV – consist of the majority of adult solid tumors

  • Bladder carcinoma, primary brain tumors, Glioblastoma, Grade III astrocytoma, Gynecological malignancies other than ovary, Colorectal carcinoma, Non-small-cell branchogenic carcinoma, Squamous-cell carcinoma, Adenocarcinoma, Large-cell carcinoma, Bronchoalveolar carcinoma, Head and neck carcinomas, Esophageal carcinoma, Gastric carcinoma, Pancreatic carcinoma, Soft-tissue sarcomas.
  • Incurable when they present with advanced metastatic diseases (stage IV)
  • Responses to therapy in less than 50% of patients
  • Short prognosis even after response to first-line chemotherapy
  • End-of-life care should be presented as a therapeutic option to patients alongside second-line chemotherapy and for patients with poor performance status (KPS or PPS less or equal 50) alongside first-line chemotherapy

Category V

  • Renal cell carcinoma, Malignant melanoma, Hepatobiliary and gall bladder carcinoma, Adrenal carcinoma, AIDS-associated high-grade lymphoma.
  • Incurable when they present with advanced metastatic diseases (stage IV)
  • Generally unresponsive to standard therapy
  • Patients who qualify may consider investigational therapy
  • End-of-life care may be the treatment of choice for this group of patients, unless they qualify for and desire investigational therapy

Regardless of cancer type, the greatest risk for cancer is advancing age. Certain cancers are more common in certain age groups, gender also plays a role in cancer prevalence. Millions of new cases of cancer diagnosed worldwide annually. Breast cancer is the most frequently diagnosed and is the leading cause of death from cancer in women worldwide, and lung cancer is the most frequently diagnosed and the leading cause of death from cancer in men worldwide. In the United States, breast cancer remains the most frequently diagnosed cancer in women, with prostate cancer as the most frequently diagnosed cancer in men. In addition, cancer is the second most common cause of death in the U.S, following heart disease. Lung cancer is the leading cause of death of men and women from cancer with a 16% survival rate for all stages combined. Breast cancer has the highest 5-year survival rate (all stages) of 89% while liver and pancreas have the lowest overall survival rate at 15% and 6%, respectively.


National Cancer Institute. (2015) Cancer Staging. Retrieved from

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