July 23, 2009 — An update to the lung cancer staging system — the first in 10 years — should improve care for patients with nonsmall-cell lung cancer (NSCLC), say experts in the field.
The new revision of the tumor-node-metastases (TNM) method for staging NSCLC is described in the July issue of Chest by a group from the Yale Cancer Center Thoracic Oncology Program at the Yale University School of Medicine in New Haven, Connecticut.
The original TNM staging system, adopted in the early 1970s, was based on a limited database of 2155 patients from 1 medical institution (the University of Texas MD Anderson Cancer Center in Houston). It was revised in 1997, still based on that 1 database, which by then consisted of 5319 cases.
This latest revision is the culmination of 10 years of work and an international effort that began in 1999. Under the auspices of the International Association for the Study of Lung Cancer (IASLC), with funding from an unrestricted grant from Eli Lilly, a new dataset was established. In its final form, it comprised 81,015 cases from 45 sources in 20 countries (58% from Europe, 21% from North America, 14% from Asia, and 7% from Australia).
"An effort of this magnitude as a basis for a staging system is quite unique among types of cancer," note the authors.
New Revision More Data-Driven
"The original system and database laid the strong foundation for lung cancer staging as we know it today," said lead author Frank Detterbeck MD, FCCP, chief of thoracic surgery at Yale University.
"However, the staging system had limitations. [Because of] the small and very narrow database, the staging system was guided by intuition rather than by evidence," he said in a statement.
"The revised IASLC staging system marks a shift to a more scientifically based, data-driven approach to lung cancer staging," he added.
"The importance of an accurate definition of a patient's cancer stage cannot be overemphasized," added senior author Lynn Tanoue, MD, FCCP, codirector of the Thoracic Oncology Program and professor of pulmonology at the Yale Cancer Center.
"It is crucial in determining the best treatment for a patient," she continued. "The new stage-classification system allows us to more precisely define a patient's prognosis and enhances our ability to share results with colleagues internationally."
One example is the case of NSCLC patients whose disease has spread to the pleural cavity. "We typically view patients with pleural dissemination as having such a poor prognosis that only palliative care is appropriate," the authors write. However, the revised staging system showed that resected patients with pleural dissemination have a relatively good prognosis, which suggests that "there may be a subgroup in [which] such a pessimistic attitude is not appropriate," they add.
Old System Served Community Well
"The TNM method for staging of NSCLC has served the lung cancer community well," writes Gene Colice MD, FCCP, from the George Washington University School of Medicine, in Washington, DC, in an accompanying editorial. "It is a useful common denominator for generally predicting outcomes and comparing treatment effects."
"This newest revision of the TNM method, which reflects an enormous effort by a dedicated group of physicians, will allow us to care for the lung cancer patient even more effectively, because the refinements in staging classifications better reflect prognosis," Dr. Colice notes.
"This revised approach should be accepted as the standard for clinicians managing NSCLC," he adds.
These sentiments were echoed by Michael Alberts, MD, FCCP, past president of the American College of Chest Physicians (ACCP). "There have been significant advances in the diagnosis and therapy for lung cancer since the last revision," he said in a statement. "The old system served us well. However, the new system has been eagerly awaited and will be used in the third edition of the ACCP Lung Cancer Guidelines."
Not To Be Used for Selecting Treatment
Although the staging system provides information on the extent of the cancer and the corresponding prognosis, it does not provide recommendations on treatment.
"The stage-classification system is designed to be a nomenclature tool and a tool to define prognosis; it is an inappropriate oversimplification to use it as an algorithm to select treatment," said Dr. Detterbeck.
Dr. Colice notes that the TNM staging system is based on anatomical features and empirical observations of survival. To advance beyond this system, attention needs to be focused on the biology of lung cancer, where insights can provide new ways of understanding prognosis and treatment responses, he writes.
Dr. Detterbeck and coauthors have disclosed no relevant financial relationships. Editorialist Dr. Colice reports having carried out work for Teva, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Lilly, MedImmune, Forest, and Almirall.
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