July 01, 2019
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Sixty years of change at the AJCC keep its ‘language of cancer’ relevant

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David P. Winchester
David P. Winchester

The American Joint Committee on Cancer, or AJCC, is celebrating its diamond anniversary as the world’s standard-bearer of communicating cancer staging.

After 60 years of harmonizing how health care professionals describe the extent of disease, HemOnc Today spoke with two AJCC insiders about how the organization has remained relevant amid an ever-changing cancer care landscape and how it plans to do so into the future.

The AJCC was organized in 1959 under the direction of the American College of Surgeons to standardize the anatomic staging of cancer. The AJCC’s classification was based on the TNM system — developed by Pierre Denoix — which considered tumor size, lymph node status and metastatic features. Input from dozens of international organizations, professional societies and health care professionals over the past 6 decades has resulted the current AJCC cancer staging system, which is detailed in the AJCC Cancer Staging Manual, a 1,032-page tome currently in its 8th edition.

“It’s had a tremendous impact,” David P. Winchester, MD, FACS, clinical professor of surgery at University of Chicago’s Pritzker School of Medicine and former AJCC executive director, said when asked about the development of the AJCC’s cancer staging system.

“I can’t imagine where we would be without it,” he told HemOnc Today. “It’s been of central importance for patients with cancer around the world — both through the work of the AJCC and our European colleagues.”

In 1987, the Geneva-based International Union Against Cancer (UICC), which had its own similar cancer staging criteria, joined with the AJCC in agreeing upon a commonly accepted system.

Winchester said both organizations publish separate cancer staging manuals, “but they are very similar,” he maintained.

“It has been characterized as the language of cancer because when you talk to other clinicians about how to treat various cancers, it really depends upon the location and extent of the tumor, and treatments may vary according to the extent of the tumor,” he said. “The AJCC,” he added, “is truly the language of cancer.”

Frederick L. Greene, MD, FACS
Frederick L. Greene

The AJCC initially was created to support staging for North American physicians, Frederick L. Greene, MD, FACS, medical director of cancer data services for Levine Cancer Institute at Atrium Health and an emeritus member of the AJCC Executive Committee, told HemOnc Today.

Sixty years later, AJCC staging has become a worldwide system, he added.

“We work very closely with the UICC ... which brings out a comparable edition of the staging manual every several years,” Greene said.

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“But, in many ways, the AJCC has advanced staging a bit more because we accept prognostic and molecular factors, not just the anatomic factors of staging,” he added.

Beyond anatomic factors

Greene, who served as lead editor for the 6th edition and on the editorial boards of the 7th and 8th editions of the AJCC Cancer Staging Manual, described a few aspects of AJCC’s work that have helped keep it relevant for more than 6 decades. These include diversification of the committee’s mission.

He explained that the AJCC not only develops and promotes its staging system, it also has taken on the role of educating physicians, cancer registrars and medical students.

“A lot of what the AJCC does is develop webinars and other educational tools instructing people on how to stage cancer correctly,” Greene told HemOnc Today.

The AJCC also has incorporated prognostic biological and molecular factors into the cancer staging process. This change occurred about 20 years ago, when Greene took over as lead editor of the 6th edition of the manual.

“We became convinced that if we stayed as just an anatomic system, then AJCC staging would become irrelevant in the next few years,” he said. “We felt we needed to bring in all of these predictive and prognostic molecular factors that clinicians use.”

Winchester identified this embrace of genomic data as evidence of AJCC’s adaptability, but he maintained that the current staging system does not stray from its roots.

“I’ve been associated with the AJCC for 30 years, and I’ve been able to observe the differences that have emerged over those decades. We have moved beyond anatomic staging to anatomic staging plus prognostic biologic factors, which has fine-tuned the staging of cancer and the process of choosing the right treatments,” Winchester said. “It’s been a big step forward that is ongoing, and likely won’t stop anytime soon.”

Time to ditch the (print) manual?

When asked to consider the main challenges facing the AJCC, Greene laid down two themes: complexity and change. The AJCC, he said, is working to address problems in both areas.

The first involves the complexity of cancer staging. Greene pointed to breast cancer as an example.

“With all the permutations and prognostic factors, a clinician can’t keep all of the information in his or her head anymore. We are working on technology that can be used in mobile devices that will aid the clinician in the staging of cancer because it’s too complex,” he said.

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“Also, we want to make it seamless for software vendors to work with our cancer registries in the United States and electronic medical records, to make AJCC staging a part of their system,” Greene explained.

The AJCC has been working with several IT groups to develop an API — an application-program interface — that translates the entire AJCC manual into programming languages, making it easier to license the book while minimizing any mistakes that can occur when translating from a print edition to a digital one.

Then Greene dropped a bombshell, at least for book lovers.

“We don’t know whether we should come out with a 9th edition. Things are happening so quickly in medicine — especially in cancer treatment — that coming out with a new edition every 5 or 6 years could be an artificial schedule. In the future, we may want to do this as a rolling update via the internet that allows for updates as quickly as possible that don’t require a rigid schedule.”

We asked Greene if this update system would be similar to what the NCCN does with its practice guidelines.

“Absolutely,” he replied. “This is what we are debating right now.”

Greene said the AJCC board will discuss the topic when it meets in Washington, D.C., in mid-July.

Given the AJCC’s history of doing what is necessary to remain relevant, it’s not hard to imagine that the board would embrace this change away from a print edition for any number of reasons. Perhaps, sometime soon, the AJCC Cancer Staging Manual — the official dictionary of cancer staging — won’t really be a physical “manual” at all. The only question is, what will clinicians do with all that extra shelf space? – by Drew Amorosi

For more information:

Frederick L. Greene, MD, FACS, can be reached at 128 Altondale Ave., Charlotte, NC 28207; email: frederick.greene@atriumhealth.org..

David P. Winchester, MD, FACS, can be reached at DW4382056@gmail.com.

Reference:

Denoix PF. Nomenclature classification des cancers. Bull Inst Nat Hyg (Paris). 1994;1:52-82.

Disclosure: Greene and Winchester report no relevant financial disclosures.