The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging.

The American Joint Committee on Cancer (AJCC) staging manual has become the benchmark for classifying patients with cancer, defining prognosis, and determining the best treatment approaches. Many view the primary role of the tumor, lymph node, metastasis (TNM) system as that of a standardized classification system for evaluating cancer at a population level in terms of the extent of disease, both at initial presentation and after surgical treatment, and the overall impact of improvements in cancer treatment. The rapid evolution of knowledge in cancer biology and the discovery and validation of biologic factors that predict cancer outcome and response to treatment with better accuracy have led some cancer experts to question the utility of a TNM-based approach in clinical care at an individualized patient level. In the Eighth Edition of the AJCC Cancer Staging Manual, the goal of including relevant, nonanatomic (including molecular) factors has been foremost, although changes are made only when there is strong evidence for inclusion. The editorial board viewed this iteration as a proactive effort to continue to build the important bridge from a "population-based" to a more "personalized" approach to patient classification, one that forms the conceptual framework and foundation of cancer staging in the era of precision molecular oncology. The AJCC promulgates best staging practices through each new edition in an effort to provide cancer care providers with a powerful, knowledge-based resource for the battle against cancer. In this commentary, the authors highlight the overall organizational and structural changes as well as "what's new" in the Eighth Edition. It is hoped that this information will provide the reader with a better understanding of the rationale behind the aggregate proposed changes and the exciting developments in the upcoming edition. CA Cancer J Clin 2017;67:93-99. © 2017 American Cancer Society.

Sixty years of CA: a cancer journal for clinicians.

The first issue of CA: A Cancer Journal for Clinicians was published in November of 1950. On the 60th anniversary of that date, we briefly review several seminal contributions to oncology and cancer control published in our journal during its first decade.

High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action.

OBJECTIVES: To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States. BACKGROUND: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown. METHODS: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis. RESULTS: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985). CONCLUSIONS: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

Improving the TNM classification: findings from a 10-year continuous literature review.

The Union for International Cancer Control's (UICC) TNM classification is a globally accepted system to describe the anatomic extent of malignant tumors. Since its development seventy years ago, the TNM classification has undergone significant revisions to reflect the current understanding of extent of disease and its role in prognosis. To ensure that revisions are evidence-based, the UICC implemented a process for continuous improvement of the TNM classification that included a formalized system for submitting proposals for revisions directly to the UICC and an annual review of the scientific literature on staging that assessed, criticized or made suggestions for changes. The process involves review of the proposals and literature by a group of international, multidisciplinary Expert Panels. The process has been in place for 10 years and informed the development of the 7th edition of the TNM classification published in 2009. The purpose of this article is to provide a description of the annual literature review process, including the search strategy, article selection process and the roles and requirements of the Expert Panels in the review of the literature. Since 2002, 147 Expert Panel members in 11 cancer sites have reviewed over 770 articles. The results of the annual literature reviews, Expert Panel feedback and documentation and dissemination of results are described.

Cancer staging in outcomes assessment.

The T N M staging system created by a surgeon in the 1950s continues to be a major benchmark for assessing long-term outcomes in adult solid tumors. Although several major changes have occurred in this anatomical staging system, the tenets of TNM staging remain constant. Recently molecular markers and biologic modifiers have been added to this anatomical staging system to create a more robust outcomes tool.

'Evidence-based medicine: the time has come to set standards for staging'. Is a radical overhaul really needed?

This Invited Response addresses concerns and opinions expressed in an Invited Commentary, 'Evidence-based medicine: the time has come to set standards for staging', by Quirke et al., published in this issue of The Journal of Pathology.

The role of the hospital registry in achieving outcome benchmarks in cancer care.

The hospital registry is a valuable tool for evaluating quality benchmarks in cancer care. As payment for performance standards are adopted, the registry will assume a more dynamic and economically important role in the hospital setting. At Carolinas Medical Center, the registry has been a key instrument in the comparison of state and national benchmarks and for program improvement in meeting standards in the care of breast and colon cancer. One of the significant successes of the American College of Surgeons Commission on Cancer (CoC) Hospital Approvals Program is the support of hospital registries, especially in small and midsized community hospitals throughout the United States. To become a member of the Hospital Approvals Program, a registry must be staffed appropriately and include analytic data for patients who have their primary diagnosis or treatment at the facility 1. The current challenge for most hospitals is to prove that the registry has specific worth when many facets of care are not compensated. Unfortunately a small number of hospitals have disbanded their registries because of the short-sighted decision that the registry and its personnel are a drain on the hospital system and do not generate revenue. In the present era of meeting benchmarks for care as a prelude to being paid by third party and governmental agencies 2,3, a primary argument is that the registry can be revenue-enhancing by quantifying specific outcomes in cancer care. Without having appropriate registry and abstract capability, the hospital leadership cannot measure the specific outcome benchmarks required in the era of "pay for performance" or "pay for participation".