Prognosis in Lung Cancer: Evolution of TNM in Molecular Age
The TNM classification of lung cancer is the most consistent and solid prognosticator of the disease, but it does not explain the whole prognosis because prognosis is multifactorial. In addition to the anatomic extent of the tumor, patient and environmental factors also count. Prognosis also is dynamic, as it may be different at the time of diagnosis, after treatment or at recurrence. In the TNM classification, tumor resection plays an important role as it defines pathological staging and may modify the prognostic assessment based on clinical staging. Other than that, the TNM classification does not include blood analyses, tumor markers, genetic characteristic of the tumor or environmental factors that may account for the differences in survival among similar tumors in different geographic areas.
In order to make progress to indicate a more personalized prognosis, instead of a prognosis based on cohorts of patients with tumors of similar anatomic extent, the IASLC Staging and Prognosis Factors Committee decided to expand its activities to the study of non-anatomic prognostic factors. Therefore, in the third phase of the IASLC Lung Cancer Staging Project, the activities of the committee will be directed to further refine the TNM classification and to find available factors that can be combined with tumor staging to define prognostic groups. To some extent, this already was done with the analyses of the database used for the 7 edition. Prognostic groups with statistically significant differences were defined by combining anatomic tumor extent and very simple clinical variables, such as performance status, gender, and age. These prognostic groups were defined for clinically and pathologically staged tumors, and for small-cell and non-small cell lung cancers.
The database used for the 8 edition includes several non-anatomical elements related to the patient, the tumor and the environment that may help refine prognosis at clinical and pathological staging. Due to the limitations of the previous databases, future revisions of the TNM classification will need to be more balanced in terms of therapeutic modalities, and better populated with patients from underrepresented geographical areas, such as Africa, India, Indonesia, North, Central and South America, and South East Asia. The data contributed in the future will have to be complete regarding the TNM descriptors, and preferably prospective. The more robust the TNM, the more important its contribution to the prognostic groups.
To achieve all of the above, international collaboration is essential. Those interested in participating in this project should send an email expressing their interest to information@crab.org, stating 'IASLC staging project' in the subject of the email. The IASLC Staging and Prognostic Factors Committee has been very touched by the overwhelming generosity of colleagues around the world who have contributed cases to inform the 7 and the 8 editions of the TNM classification of lung cancer. We continue to count on their collaboration to further revise future editions and to define prognostic groups that will eventually allow a more personalized indication of prognosis.
The Future of the TNM Classification
The TNM classification of lung cancer is the most consistent and solid prognosticator of the disease, but it does not explain the whole prognosis because prognosis is multifactorial. In addition to the anatomic extent of the tumor, patient and environmental factors also count. Prognosis also is dynamic, as it may be different at the time of diagnosis, after treatment or at recurrence. In the TNM classification, tumor resection plays an important role as it defines pathological staging and may modify the prognostic assessment based on clinical staging. Other than that, the TNM classification does not include blood analyses, tumor markers, genetic characteristic of the tumor or environmental factors that may account for the differences in survival among similar tumors in different geographic areas.
In order to make progress to indicate a more personalized prognosis, instead of a prognosis based on cohorts of patients with tumors of similar anatomic extent, the IASLC Staging and Prognosis Factors Committee decided to expand its activities to the study of non-anatomic prognostic factors. Therefore, in the third phase of the IASLC Lung Cancer Staging Project, the activities of the committee will be directed to further refine the TNM classification and to find available factors that can be combined with tumor staging to define prognostic groups. To some extent, this already was done with the analyses of the database used for the 7 edition. Prognostic groups with statistically significant differences were defined by combining anatomic tumor extent and very simple clinical variables, such as performance status, gender, and age. These prognostic groups were defined for clinically and pathologically staged tumors, and for small-cell and non-small cell lung cancers.
The database used for the 8 edition includes several non-anatomical elements related to the patient, the tumor and the environment that may help refine prognosis at clinical and pathological staging. Due to the limitations of the previous databases, future revisions of the TNM classification will need to be more balanced in terms of therapeutic modalities, and better populated with patients from underrepresented geographical areas, such as Africa, India, Indonesia, North, Central and South America, and South East Asia. The data contributed in the future will have to be complete regarding the TNM descriptors, and preferably prospective. The more robust the TNM, the more important its contribution to the prognostic groups.
To achieve all of the above, international collaboration is essential. Those interested in participating in this project should send an email expressing their interest to information@crab.org, stating 'IASLC staging project' in the subject of the email. The IASLC Staging and Prognostic Factors Committee has been very touched by the overwhelming generosity of colleagues around the world who have contributed cases to inform the 7 and the 8 editions of the TNM classification of lung cancer. We continue to count on their collaboration to further revise future editions and to define prognostic groups that will eventually allow a more personalized indication of prognosis.