Cancer staging in 2022 Brian OSullivan, MD Chair, Prognostic - - PowerPoint PPT Presentation

Union for International Cancer Control

Cancer stage: a neglected cornerstone of cancer control Brian O’Sullivan, MD Chair, Prognostic Factors Task Force, UICC TNM Prognostic Factors Core Committee

August 28, 2012 Palais des congres de Montreal, Montreal,Canada

Cancer staging in 2022

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TNM – A Universal Language

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Does the need for TNM staging change over time ?

Basically: communication, prognosis, treating patients, evaluate results

Likert scales 1-7 622 oncologists

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TNM provides different needs to different groups

• Clinical trials eligibility and

stratification

• Defining and monitoring use of

clinical practice guidelines

• Translational research
• Health services and registry

uses including early successes

• f screening
• Discussing / defining treatment
• f individual patients in clinics

and conferences (tumor boards)

• Fiscal and policy development
• f cancer programs

Mackillop WJ, O’Sullivan B, Gospodarowicz M, The Role of Cancer Staging in Evidence- based Medicine Cancer Prev Control, 2(6) 269-77, 1998

Viewed through different lenses by different groups: experts in one area must appreciate the needs of

• ther groups who also use

TNM

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Aims of the Staging Classification

• 1. To aid the clinician in the planning of treatment
• 2. To give some indication of prognosis
• 3. To assist in evaluation of the results of treatment
• 4. To facilitate the exchange of information between

treatment centres

• 5. To contribute to the continuing investigation of

human cancer

• 6. To support cancer control activities (new in 7th

edition) UICC TNM Classification of Malignant Tumours, 7th edition, 2009

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Limit Limitations ions of

• f TNM

NM Cancer ancer Staging ging

• Does not describe biology of cancer
• Does not fully predict response to

chemotherapy and targeted therapy

• Misuse is frequent in implementation
• f TNM and in attempts to modify or

develop new classifications

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Cancer Prevention and Control 1998

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• Frequent revisions to include new biomarkers would undermine the

value conferred by the stability and universality of TNM

• A static formulation of TNM risks falling behind the state of the art in

diagnostic techniques, biological concepts and biomarkers

Dilemma in TNM staging:

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Prognos

• gnostic

ic Fact actor

• rs in

in Cancer ancer

• Non-anatomic prognostic factors are poorly integrated and

this area needs attention:

– No uniform system for classification available – Need to develop “taxonomy” to address this domain that does not rely solely on the TNM scaffold

• From time to time we hear statements:

– Stage classification should be modified, or discarded / eliminated because of new molecular discoveries (usually in a selected area) – These statements are only useful to underline the need to address this challenge

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Cancer ancer Prognos

• gnostic

ic Clas lassif ifica ication: ion: New New Tax axonomy

• nomy will

ill Evolv

• lve

e in in ne next xt 10 10 year ears

• Tumour anatomic extent (Staging)
• Size, depth of invasion, metastasis, location, number of lesions
• Expressed by TNM classification
• Tumour profile (Profiling)
• Histopathologic type, grade
• Molecular markers and gene expression patterns
• Hormone receptor status
• Proliferation markers
• Prognostic Index (Prognostic Risk Grouping)
• Combines Profiling, Staging, Patient and Environmental factors
• Usually for Subgroups and is Scenario-specific

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Useful in individual patients, with selected criteria (e.g. resected disease) for a specific purpose (decision for chemotherapy) Not yet useful for managing / stratifying / analysing groups of patients (see other goals of staging)

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Need to create Prognostic Risk Groups for different scenarios that address interventions and relevant end-points

Anatomic Disease Characteristics Tumor Profile Characteristics Patient / Host Characteristics Treatment / Environment Characteristics

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Standardisation of TNM to meet registration needs in different juristictions

The UICC should examine how mapping from TNM to “localised, regional, distant” systems could be made explicit and standardised for all cancers.

S Walters et al Accepted IJC

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ICD 11 5th Character

Section Malignant neoplasms: Section malignant:-- 1: Stage I 2: Stage II 3: Stage III 4: Stage IV 9: Unknown, unspec, not app A: Remission/Free of disease B: Local disease C: Regional disease D: Distant disease Note in situ has its own section

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Cancer Staging in 2022

• Will continue to evolve and maintain its anatomic

basis to permit new biological and other findings to be evaluated

• Will continue to support the numerous needs of

varying constituents that need anatomic stage

• Will be combined with Tumor, Host, and

Environmental factors to create Prognostic Risk Groups for different cancer situations

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Acknowledgements

• The members of the UICC TNM

Prognostic Factors Core Committee

• Colleagues at the AJCC and its Task

Forces

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Prediction

• Prediction is very difficult, especially about

the future.

– Niels Bohrs (Physicist)

• The best way to predict the future is to

invent it.

– Alan Kay (Computer Scientist)